Exposure to incense burning, biomarkers, and the physical health of temple workers in Taiwan.

Incense burning releases heavy particulate matter (PM) and nitrogen dioxide (NO2), known to have adverse effects on human health. Long-term exposure to PM and NO2 increases inflammatory cytokine levels and can induce respiratory diseases. This study examined the association between incense burning exposure and the health status, especially inflammatory biomarkers, of temple workers and volunteers in Taiwan. The longitudinal observational study compared adult temple workers and volunteers, with long-term incense burning exposure, to residents from outpatient clinics in the Chiayi area. Forced expiratory volume in 1 s (FEV1) and serum and exhaled breath condensate (EBC) cytokines were assessed. Nonparametric Mann-Whitney U tests were used to compare cytokine levels of the exposure and control groups during the cold and hot weather seasons. FEV1 was significantly more diminished in the exposed group than in the control group during the cold season. Exposure status was associated with greater hot-cold seasonal differences in serum interleukins (IL)-1ß (regression coefficient (B) = 6.6, 95% confidence interval (CI) = 5.0 to 8.3, p < .001), IL17-A (B = 2.4, 95% CI = 0.3 to 4.5, p = .03), and plasminogen activator inhibitor [PAI]-1 (B = 5.4, 95% CI = 1.5 to 9.3, p = .009). After adjusting for confounders, the groups' serum levels of IL-1ß, IL-17A, and PAI-1 significantly differed. EBC cytokines did not show significant differences. Elevated levels of IL-1ß, IL17-A, and PAI-1 have been associated with various autoinflammatory syndromes and diseases. Given the cultural significance of incense burning, culturally sensitive interventions, including education, policy development, and program implementation, are crucial to protect individuals' health, especially temple workers, from the adverse effects of exposure, addressing the manufacture, importation, and sale of incense.

Growth mixture models: a case example of the longitudinal analysis of patient-reported outcomes data captured by a clinical registry.

BACKGROUND: An assumption in many analyses of longitudinal patient-reported outcome (PRO) data is that there is a single population following a single health trajectory. One approach that may help researchers move beyond this traditional assumption, with its inherent limitations, is growth mixture modelling (GMM), which can identify and assess multiple unobserved trajectories of patients' health outcomes. We describe the process that was undertaken for a GMM analysis of longitudinal PRO data captured by a clinical registry for outpatients with atrial fibrillation (AF). METHODS: This expository paper describes the modelling approach and some methodological issues that require particular attention, including (a) determining the metric of time, (b) specifying the GMMs, and (c) including predictors of membership in the identified latent classes (groups or subtypes of patients with distinct trajectories). An example is provided of a longitudinal analysis of PRO data (patients' responses to the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Questionnaire) collected between 2008 and 2016 for a population-based cardiac registry and deterministically linked with administrative health data. RESULTS: In determining the metric of time, multiple processes were required to ensure that "time" accounted for both the frequency and timing of the measurement occurrences in light of the variability in both the number of measures taken and the intervals between those measures. In specifying the GMM, convergence issues, a common problem that results in unreliable model estimates, required constrained parameter exploration techniques. For the identification of predictors of the latent classes, the 3-step (stepwise) approach was selected such that the addition of predictor variables did not change class membership itself. CONCLUSIONS: GMM can be a valuable tool for classifying multiple unique PRO trajectories that have previously been unobserved in real-world applications; however, their use requires substantial transparency regarding the processes underlying model building as they can directly affect the results and therefore their interpretation.

Patient-reported outcomes and the identification of subgroups of atrial fibrillation patients: a retrospective cohort study of linked clinical registry and administrative data.

PURPOSE: Previous research about the health and quality of life of people with atrial fibrillation has typically identified a single health trajectory. Our study aimed to examine variability in health trajectories and patient characteristics associated with such variability. METHODS: We conducted a retrospective analysis of data collected between 2008 and 2016 for a cardiac registry in British Columbia (Canada) linked with administrative health data. The Atrial Fibrillation Effect on Quality of Life Questionnaire was used to measure health status at up to 10 clinic visits. Growth mixture models were used and a three-step multinomial logistic regression was conducted to identify predictors of subgroups with different trajectories. RESULTS: The patients (N = 7439) were primarily men (61.1%) over 60 years of age (72.9%). Three subgroups of health status trajectories were identified: "poor but improving", "good and stable", and "excellent and stable" health. Compared with the other two groups, patients in the "poor but improving group" were more likely to (1) be less than 60 years of age; (2) be women; (3) have greater risk of stroke; (4) have had ablation therapy within 6 months to 1 year or more than 2 years after their initial consultation; and (5) have had anticoagulation therapy within 6 months. CONCLUSION: Using growth mixture models, we found that not all health trajectories are the same. These models can help to understand variability in trajectories with different patient characteristics that could inform tailored interventions and patient education strategies.

Racism Is Not a Factor in Door-to-electrocardiogram Times of Patients With Symptoms of Acute Coronary Syndrome: A Prospective, Observational Study.

BACKGROUND: Investigators have identified important racial identity/ethnicity-based differences in some aspects of acute coronary syndrome (ACS) care and outcomes (time to presentation, symptoms, receipt of coronary angiography/revascularization, repeat revascularization, mortality). Patient-based differences such as pathophysiology and treatment-seeking behavior account only partly for these outcome differences. We sought to investigate whether there are racial identity/ethnicity-based variations in the initial emergency department (ED) triage and care of patients with suspected ACS in Canadian hospitals. METHODS: We prospectively enrolled ED patients with suspected ACS from one university-affiliated and two community hospitals. Trained research assistants administered a standardized interview to gather data on symptoms, treatment-seeking patterns, and self-reported racial/ethnic identity: "white," South Asian" (SA), "Asian," or "Other." Clinical parameters were obtained through chart review. The primary outcome was door-to-electrocardiogram (D2ECG) time. ECG times were log-transformed and two linear regression models, controlling for important demographic, system, and clinical factors, were fit. RESULTS: Of 448 participants, 214 (48%) reported white identity, 115 (26%) SA, 83 (19%) Asian, and 36 (8%) "Other." Asian respondents were younger and more likely to report initial discomfort as "low" and be accompanied by family; respondents identifying as "Other" were more likely to report initial discomfort as "high." There was no difference in D2ECG time between white participants and all other groups, but there were statistically significant differences by sex: women had longer D2ECG times than men. Exploring more specific racial identities revealed similar findings: no significant differences between the white, SA, Asian, and other groups, while sex (women had 13.4% [95% confidence interval, 0.81%-27.57%] longer D2ECG times) remained statistically significantly different in the adjusted models. CONCLUSION: Although racial/ethnicity-based differences in aspects of ACS care have been previously identified, we found no differences in the current study of early ED care in a Canadian urban setting. However, female patients experience longer D2ECG times, and this may be a target for process improvements.

A cross-sectional study of ethnicity-based differences in treatment seeking for symptoms of acute coronary syndrome.

BACKGROUND: Patient-related delays in acquiring medical care for symptoms of acute coronary syndrome remain unacceptably long. Many clinical and sociodemographic characteristics associated with treatment-seeking delay are known; however, ethnicity has not been extensively evaluated. OBJECTIVE: The purpose of this study was to examine ethnicity-based differences in the time-to-treatment-seeking intervals of patients experiencing symptoms of acute coronary syndrome. METHOD: Data for this descriptive study were collected for the larger Acute Coronary Syndrome Care in Emergency Departments (ASCEND) study. The larger study is a prospective, observational study in which patients presenting to hospital emergency departments and triaged as having symptoms suggestive of acute coronary syndrome are identified. The primary outcome of this study, the time-to-treatment-seeking interval, was defined as the time between symptom onset and treatment seeking. The predictor variable, ethnicity, was measured with self-reported data and categorised as Chinese, South Asian, or 'Other' ethnic group. Participants in the 'Other' ethnic group were predominantly of European ancestry. Univariate and multivariate analyses were undertaken, along with nonparametric testing. RESULTS: The study sample consisted of 419 participants: 36 Chinese, 126 South Asian, and 257 'Other' participants. The median time-to-treatment-seeking interval, for the total sample, was 180 minutes. A Kruskal-Wallis test demonstrated no statistically significant differences in the time-to-treatment-seeking intervals by ethnicity. CONCLUSION: No ethnicity-based differences in the time-to-treatment-seeking intervals for symptoms of acute coronary syndrome were found. It is possible that Chinese and South Asian patients living in western countries are more aware of the potential signs and symptoms of acute coronary syndrome or feel more confident to access healthcare services than they have been previously.

Practice Change Interventions in Long-Term Care Facilities: What Works, and Why?

Over the past three decades, there has been a notable increase in studies of practice change interventions in long-term care (LTC) settings. This review, based on a modified realist approach, addresses the following questions: What practice change intervention characteristics work? And, in what circumstances do they work and why? A modified realist approach was applied to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases and published literature for empirical studies of practice change interventions that (a) were conducted in LTC settings, (b) involved formal care staff members, and (c) reported a formal evaluation. Ninety-four articles met the inclusion criteria. Interventions that included only predisposing factors were least likely to be effective. Interventions that included reinforcing factors were most likely to produce sustained outcomes. We concluded that interventions aimed at practice change in LTC settings should include feasible and effective enabling and reinforcing factors.

Life stress as a mediator and community belonging as a moderator of mood and anxiety disorders and co-occurring disorders with heavy drinking of gay, lesbian, bisexual, and heterosexual Canadians.

PURPOSE: To examine the extent to which sexual identity disparities in mental health outcomes (anxiety disorder, mood disorder, anxiety-mood disorder, and co-occurring anxiety or mood disorder and heavy drinking) are mediated by life stress or moderated by a sense of community belonging. METHODS: This study pooled data from a large, national, multi-year sample of Canadians aged 18-59 years, who self-identified as lesbian, gay, bisexual, or heterosexual (N = 222,548). A series of stratified binary mediation models were fitted. Significance of the indirect effect was determined by using bootstrapping to obtain standard errors and confidence intervals. RESULTS: Sexual minority (versus heterosexual) respondents were significantly more likely to describe their lives as stressful, their sense of community belonging as weak, and had significantly greater odds of the negative mental health outcomes. Perceived life stress partially mediated the effects of sexual identity on the mental health outcomes. The differences between the mediated effects for the gay/lesbian and bisexual subgroups were statistically significant (all p < 0.05). When stratified by sense of community belonging, life stress mediated the relationship with mood disorders for the gay/lesbian group, where a strong sense of community belonging was associated with greater odds of mood disorders for gay/lesbian versus heterosexual respondents. CONCLUSIONS: These mediation and moderated mediation models provide further evidence for a social patterning of the mental health disparities experienced by sexual minorities in Canada.

The Accuracy of Computerized Adaptive Testing in Heterogeneous Populations: A Mixture Item-Response Theory Analysis.

BACKGROUND: Computerized adaptive testing (CAT) utilizes latent variable measurement model parameters that are typically assumed to be equivalently applicable to all people. Biased latent variable scores may be obtained in samples that are heterogeneous with respect to a specified measurement model. We examined the implications of sample heterogeneity with respect to CAT-predicted patient-reported outcomes (PRO) scores for the measurement of pain. METHODS: A latent variable mixture modeling (LVMM) analysis was conducted using data collected from a heterogeneous sample of people in British Columbia, Canada, who were administered the 36 pain domain items of the CAT-5D-QOL. The fitted LVMM was then used to produce data for a simulation analysis. We evaluated bias by comparing the referent PRO scores of the LVMM with PRO scores predicted by a "conventional" CAT (ignoring heterogeneity) and a LVMM-based "mixture" CAT (accommodating heterogeneity). RESULTS: The LVMM analysis indicated support for three latent classes with class proportions of 0.25, 0.30 and 0.45, which suggests that the sample was heterogeneous. The simulation analyses revealed differences between the referent PRO scores and the PRO scores produced by the "conventional" CAT. The "mixture" CAT produced PRO scores that were nearly equivalent to the referent scores. CONCLUSION: Bias in PRO scores based on latent variable models may result when population heterogeneity is ignored. Improved accuracy could be obtained by using CATs that are parameterized using LVMM.

Prevalence and Co-Occurrence of Heavy Drinking and Anxiety and Mood Disorders Among Gay, Lesbian, Bisexual, and Heterosexual Canadians.

OBJECTIVES: To investigate the prevalence and co-occurrence of heavy drinking, anxiety, and mood disorders among Canadians who self-identified as gay, lesbian, bisexual, or heterosexual. METHODS: Pooled data from the 2007 to 2012 cycles of the Canadian Community Health Survey (n = 222 548) were used to fit logistic regression models controlling for sociodemographic characteristics. RESULTS: In adjusted logistic regression models, gay or lesbian respondents had greater odds than heterosexual respondents of reporting anxiety disorders, mood disorders, and anxiety-mood disorders. Bisexual respondents had greater odds of reporting anxiety disorders, mood disorders, anxiety-mood disorders, and heavy drinking. Gay or lesbian and bisexual respondents had greater odds than heterosexuals of reporting co-occurring anxiety or mood disorders and heavy drinking. The highest rates of disorders were observed among bisexual respondents, with nearly quadruple the rates of anxiety, mood, and combined anxiety and mood disorders relative to heterosexuals and approximately twice the rates of gay or lesbian respondents. CONCLUSIONS: Members of sexual minority groups in Canada, in particular those self-identifying as bisexual, experience disproportionate rates of anxiety and mood disorders, heavy drinking, and co-occurring disorders.

Examining the relationship between personality and affect-related attributes and adolescents' intentions to try smoking using the Substance Use Risk Profile Scale.

Assessments of adolescents' smoking intentions indicate that many are susceptible to smoking initiation because they do not have resolute intentions to abstain from trying smoking in the future. Although researchers have developed personality and affect-related risk factor profiles to understand risk for the initiation of substance use and abuse (e.g., alcohol), few have examined the extent to which these risk factors are related to the tobacco use intentions of adolescents who have yet to try tobacco smoking. The objective of this study was to examine the relationships between personality and affect-related risk factors measured by the Substance Use Risk Profile Scale (SURPS) and smoking intentions in a sample of adolescents who have not experimented with tobacco smoking. Data is based on responses from 1352 participants in the British Columbia Adolescent Substance Use Survey (56% female, 76% in Grade 8) who had never tried smoking tobacco. Of these 1352 participants, 29% (n=338) were classified as not having resolute intentions to not try smoking. Generalized estimating equations were used to examine the relationship between each SURPS dimension (Anxiety Sensitivity, Hopelessness, Impulsivity and Sensation Seeking) and the intention to try cigarettes in the future. Hopelessness (AOR 1.06, 95% CI [1.03, 1.10], p<.001), Impulsivity (AOR 1.07 [1.03, 1.11], p<.001) and Sensation Seeking (AOR 1.05 95% CI [1.02, 1.09], p<.01) had independent statistically significant associations with having an intention to try smoking. These findings may be used to inform a prevention-oriented framework to reduce susceptibility to tobacco smoking.

The Influence of Organizational Systems on Information Exchange in Long-Term Care Facilities: An Institutional Ethnography.

Person-centered care is heavily dependent on effective information exchange among health care team members. We explored the organizational systems that influence resident care attendants' (RCAs) access to care information in long-term care (LTC) settings. We conducted an institutional ethnography in three LTC facilities. Investigative methods included naturalistic observations, in-depth interviews, and textual analysis. Practical access to texts containing individualized care-related information (e.g., care plans) was dependent on job classification. Regulated health care professionals accessed these texts daily. RCAs lacked practical access to these texts and primarily received and shared information orally. Microsystems of care, based on information exchange formats, emerged. Organizational systems mandated written exchange of information and did not formally support an oral exchange. Thus, oral information exchanges were largely dependent on the quality of workplace relationships. Formal systems are needed to support structured oral information exchange within and between the microsystems of care found in LTC.

The relationship between language proficiency and surgical length of stay following cardiac bypass surgery.

BACKGROUND: Anglophone nurses face the challenge of communicating health information to patients who do not speak or understand English. Limited English-proficient patients are at higher risk of misinterpreting health information teaching. Successful recovery after coronary artery bypass graft surgery requires patients' engagement with healthcare professionals and active participation in therapies and related undertakings. Determination of whether limited English-proficient patients undergoing coronary artery bypass graft surgery recover at the same pace as the general population is of interest. AIM: This study examined whether limited English-proficient patients had prolonged post-operative length of stay following coronary artery bypass graft surgery. The patients' length of stay with regard to a clinical pathway target was also examined. METHOD: A retrospective medical record review of all patients undergoing isolated coronary artery bypass graft surgery in a 2-year period was conducted. A screening tool was developed to identify limited English-proficient patients through examination of their medical records. RESULTS: A total of 691 of 712 (97.1%) patients met the inclusion criteria; 103 (14.9%) patients were identified as limited English-proficient. The post-operative median length of stay of limited English-proficient patients was 7 days compared with 6 days for the English-proficient patients (p = 0.007). Limited English-proficient patients had higher infection rates (29.1%) vs. English-proficient patients (16.7%) (odds ratio = 2.05 (95% confidence intervals 1.27-3.30)). Post-operative infection was the strongest predictor of length of stay and fully mediated the relationship between language proficiency and length of stay. CONCLUSION: When compared with English-proficient patients, limited English-proficient patients had greater infection rates, which were associated with longer length of stay. These findings warrant examination of the mechanisms through which post-operative infections are acquired by limited English-proficient patients.

Sex is associated with differences in individual trajectories of change in social health after implantable cardioverter-defibrillator.

BACKGROUND: Social health is a dimension of quality of life, and refers to people's involvement in, and satisfaction with social roles, responsibilities, and activities. The implantable cardioverter-defibrillator is associated with changes in overall quality of life, but little is known about sex differences in individual trajectories of change in social health. METHODS AND RESULTS: We prospectively measured changes in 3 subscales of the SF-36v2 generic health questionnaire (role physical, role emotional, and social functioning), 2 Patient-Reported Outcomes Measurement Information System short forms (satisfaction with participation in social roles and satisfaction with participation in discretionary social activities), and the Florida Patient Acceptance Survey before and at 1, 2, and 6 months after implantation. Individual growth models of temporal change were estimated. The scores of the 6 indicators improved with time. The unconditional model demonstrated significant (fixed effects: P<0.05; covariance parameters: P<0.10) residual variability in the individual trajectories. In the conditional model, men and women differed significantly in their rates of change in the scores of 3 of the 6 measures. Although men's mean scores exceeded women's mean scores on all indicators at baseline (range of relative mean difference: 11.0% to 17.8%), the rate of women's change resulted in a reversal in relative standing at 6 months after implantation, with the mean scores of women exceeding the men's by 4.5% to 5.6%. CONCLUSIONS: Men and women differed in their trajectories of change in social health, both in terms of their starting points (ie, baseline scores) and their rates of change.

Effect of web-based messages on girls' knowledge and risk perceptions related to cigarette smoke and breast cancer: 6-month follow-up of a randomized controlled trial.

BACKGROUND: Evidence indicating an association between cigarette smoke exposure and an increase in breast cancer risk highlights the need for health messages that aim to prevent smoking initiation and reduce secondhand smoke (SHS) exposure among adolescent girls. OBJECTIVE: This study aimed to evaluate the efficacy of targeted gender-sensitive, breast cancer-specific, Web-based messages about the increased risk of breast cancer associated with cigarette smoke exposure. Outcomes assessed 6 months postmessage delivery included nonsmoking adolescent girls' knowledge of the link between cigarette smoke exposure and breast cancer, perceptions of breast cancer risk associated with cigarette smoke, smoking behavior and intentions, and stage of change related to avoidance of secondhand smoke. METHODS: A prospective randomized controlled trial was used to compare standard (control) messages with targeted gender- and Aboriginal status-sensitive, breast cancer-specific (intervention) messages. Messages were delivered online to 618 nonsmoking girls, aged 13 to 15 years, clustered in 74 Canadian secondary schools. RESULTS: Compared with the control group, girls in the intervention group were significantly more likely to report that breast cancer is an illness caused by cigarette smoke (adjusted relative risk [ARR] 1.33, 95% CI 1.05-1.68) and to agree that exposure to SHS increases their risk of breast cancer (ARR 1.10, 95% CI 1.02-1.20). No significant effects were observed for a change in smoking status, intention to try smoking, or stage of change related to avoidance of SHS. CONCLUSIONS: Compared with standard messages, targeted gender-sensitive, breast cancer-specific messages had a stronger influence on girls' knowledge and perceived risk of cigarette smoke exposure as a risk factor for breast cancer. Brief information-based interventions delivered over the Internet have the potential to provide effective health promotion that could be broadly disseminated and lead to long-term effects on girls' knowledge and risk perceptions about cigarette exposure and breast cancer.

The privileged normalization of marijuana use - an analysis of Canadian newspaper reporting, 1997-2007.

The objective of this study was to systematically examine predominant themes within mainstream media reporting about marijuana use in Canada. To ascertain the themes present in major Canadian newspaper reports, a sample (N = 1999) of articles published between 1997 and 2007 was analyzed. Drawing from Manning's theory of the symbolic framing of drug use within media, it is argued that a discourse of 'privileged normalization' informs portrayals of marijuana use and descriptions of the drug's users. Privileged normalization implies that marijuana use can be acceptable for some people at particular times and places, while its use by those without power and status is routinely vilified and linked to deviant behavior. The privileged normalization of marijuana by the media has important health policy implications in light of continued debate regarding the merits of decriminalization or legalization and the need for public health and harm reduction approaches to illicit drug use.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature.

BACKGROUND: Patients' treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research. METHODS AND RESULTS: We reviewed the English-language literature from 1998-2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing. CONCLUSION: We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.

The gender-specific association between asthma and the need to smoke tobacco.

OBJECTIVES: To examine the associations between multidimensional tobacco dependence and youths' asthma status with gender as an effect modifier. BACKGROUND: Despite the adverse respiratory effects, some adolescents with asthma smoke tobacco. Girls and boys have been shown to have different motivations for tobacco use. METHODS: Secondary analyses were conducted of data obtained from 1248 adolescents who completed the British Columbia Youth Survey of Smoking and Health II. The sample was limited to youth who reported current or experimental tobacco use and who provided asthma status information. Tobacco dependence was assessed with the modified-Fagerström Tolerance Questionnaire and four-dimension Adolescents' Need for Smoking Scale (ANSS), which assesses social dependence, physical dependence, emotional dependence, and sensory dependence on tobacco. All analyses were stratified by gender. RESULTS: The sample was 535 boys and 713 girls who were 15.9 years of age (SD = 1.5), on average. Gender was associated with both self-reported asthma status and the physical dependence dimension of the ANSS. Multiple linear regression analyses revealed that girls with asthma, compared with girls without asthma, had higher physical tobacco dependence scores, after adjusting for demographic and other factors. None of the tobacco dependence dimensions was associated with the asthma status of boys. CONCLUSIONS: Asthmatic girls who report smoking may be doing so because they develop physical dependence relatively quickly and lose their autonomy with respect to tobacco use. They may require significant support for smoking cessation, including cognitive behavioral therapy and nicotine replacement therapy.

Gender-based measurement invariance of the substance use risk profile scale.

Gender may influence the psychometric properties of psychological and affect-related measures. The American Psychological Association has made recommendations to conduct tests of group-level measurement invariance (MI) before comparing scores between groups. Gender-based measurement invariance has been examined in many well-known psycho-social scales such as the CES-D and the Big Five Inventory. The Substance Use Risk Profile is a 23-item scale measuring affective- and personality-related traits known to increase risk for substance use, with 4 dimensions: anxiety sensitivity, hopelessness, sensation seeking and impulsivity. Despite similarities in the constructs assessed by the SURPS, the CES-D and the Big Five Inventory, gender-based measurement invariance of the SURPS has not yet been published. Multi-group confirmatory factor analysis was used to assess the measurement invariance of the four dimensions of the SURPS across gender. MI was conducted with M-Plus 6.2 using a 2-step analysis for ordinal variables suggested by Muthén and Muthén, and model fit was assessed using the comparative fit index (CFI) criteria recommended by Cheung and Rensvold. A single group confirmatory factor analysis (CFA) was also conducted. The sample was composed of 1352 adolescents (56% female, mean age of 14years) participating in the BC Adolescent Substance Use Survey, an online survey capturing substance use and psychosocial trends in secondary students across British Columbia, Canada. Measurement invariance across gender was demonstrated for the SURPS (ΔCFI=0.003), and the single group CFA supported a four-dimensional structure for the SURPS items (CFI=0.92, RMSEA=061, 95% CI=0.058-0.065).

Initial impact of tailored web-based messages about cigarette smoke and breast cancer risk on boys' and girls' risk perceptions and information seeking: randomized controlled trial.

BACKGROUND: Recent evidence indicates a causal link between both active smoking and secondhand smoke (SHS) exposure and breast cancer (BC). OBJECTIVE: The objective of the present study was to evaluate the initial reactions of girls and boys to tailored Web-based messages that describe the relationship between SHS and BC, using a parallel, single-blinded cluster randomized controlled trial. METHODS: This trial was nested within a cycle of an ongoing longitudinal study of 1498 students from 74 secondary schools. Self-reported assessments were used to evaluate the impact of study messages on participants' risk perception and interest in obtaining additional information after participants were randomized by schools to control or intervention groups. The intervention group received a tailored visual message (based on gender and Aboriginal status) about BC and tobacco smoke. The control group received a standard visual message about smoking and cancer. RESULTS: SHS exposure was identified as a BC risk factor by 380/1488 (25.54%) participants, during the preintervention analysis. Compared to the female participants in the control group (491/839, 58.5%), girls who received the intervention (339/649, 52.2%) were 14% more likely to agree that exposure to SHS increased their BC risk (relative risk [RR] 1.14, 95% CI 1.07-1.21). Nonsmoking girls who received the intervention were 14% more likely to agree that starting smoking would increase their BC risk (RR 1.14, 95% CI 1.07-1.21). Compared to the male participants in control group (348/839, 41.5%), boys who received the intervention (310/649, 47.8%) were 10% more likely to agree that girls' exposure to SHS increased their BC risk (RR 1.10, 95% CI 1.02-1.18). Compared to controls, girls who received the intervention were 52% more likely to request additional information about SHS and BC (RR 1.52, 95% CI 1.12-2.06). CONCLUSIONS: Brief gender-sensitive messages delivered via the Internet have the potential to increase awareness and to stimulate information seeking about the risk for BC associated with SHS.

The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study.

BACKGROUND: Post-operative delirium after cardiac surgery is an adverse event that affects patients' recovery and complicates the delivery of nursing care. Numerous risk factors for delirium are uncontrollable; however, nurses' pro re nata drug administration of sedatives may be a controllable risk factor. OBJECTIVES: This study examined the relationship between nurses' pro re nata administration of midazolam hydrochloride to cardiac surgery patients and the development of post-operative delirium. DESIGN: Observational study. SETTING: Cardiac surgery intensive care and nursing units of a tertiary care center in Vancouver, Canada. PARTICIPANTS: 122 male and female patients requiring non-emergent surgery for coronary artery disease or valvular heart disease who did not have pre-existing cognitive impairment, severe hearing or visual impairment, substance misuse, alcohol intake exceeding 7 drinks per week, or renal impairment requiring hemodialysis. METHODS: Patients were assessed for delirium, on three occasions, with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) during the first 72 h after surgery and through reviews of physicians' notes. Risk factor and midazolam dosage data were collected from medical records. RESULTS: 77.9% of the patients in this sample received midazolam hydrochloride post-operatively. The prevalence of delirium ranged from 37.7% to 44.3%. Almost all of the dosages of midazolam (85-87%) were given before the first indication of delirium; that is, most of the patients had received their entire dosage before the first signs of delirium were detected. Bivariate analysis with logistic regression models revealed that for every additional milligram of midazolam administered, the patients were 7-8% more likely to develop delirium. Multivariate logistic regression models demonstrated that the magnitude of the association between midazolam dosage and delirium was not confounded by established risk factors including age and peripheral vascular disease. CONCLUSION: Nurses play an important role in the prediction, assessment and prevention of post-operative delirium. Sedatives should be administered with caution because they increase a patient's risk of developing delirium. Nurses' decisions regarding sedation administration must be informed by empirical knowledge, accurate assessment data and clear rationale with consideration of how these actions may contribute to the development of delirium.