[Prospective evaluation of our protocol for screening gestational diabetes by O'Sullivan's test]. / Evaluation prospective de notre protocole de dépistage du diabète gestationnel avec le test de O'Sullivan.

OBJECTIVES: We evaluated prospectively our protocol for screening diabetes during pregnancy. PATIENTS AND METHODS: We applied recommendations of the French National College for Obstetricians and Gynecologists with screening by O'Sullivan's test and HGPO with 100g when the result was greater than 1.40 g/l. This protocol was discussed and approved by our team including a neonatalogist. RESULTS: We included 780 patients delivered between the 1(st) January and the 1(st) October 2005. Between them, 628 were screened (80.5%) and 39 presented gestational diabetes (39/628=6.2%). Fetal ultrasound at 38 weeks of amenorrhea was included in our protocol but applied only for 25.8% of our patients. In the subgroup with gestational diabetes, the rate of induction of labor was 38.4% (15/39), with a cesarean delivery for 23% (9/39) and macrosomia for 20.5% (8/39) of the newborn. CONCLUSIONS: This study showed us that we have to improve the application of our protocol and to try to obtain a shorter time between the two test, O'Sullivan and HGPO, when performed.

Temporal patterns of disruptive vocalization in elderly nursing home residents.

This study used computer-assisted real-time data collection procedures to study temporal patterns of disruptive vocalization (DV) in demented nursing home residents. Residents (N = 68) were observed from 8 a.m. to 8 p.m. and total mean duration of DV within hourly blocks was calculated. Analysis of the temporal distribution of DV exhibited by the group of 68 residents indicated a significant cubic trend. Exploratory cluster analysis uncovered three distinct temporal patterns of DV; although two of the patterns are generally supportive of sundowning. Cluster 1 showed a relatively constant pattern of low rate DV. Clusters 2 and 3 showed cyclic trends. Peaks in DV were observed during noontime and in the evening for Cluster 2. Cluster 3 showed peaks in DV in the early morning hours and late afternoon. MANOVA was employed to examine any differences among clusters in age, cognitive status, and ADL status. Univariate analyses indicated that cognitive status was the only factor that differed significantly among clusters, with members of Cluster 1 (constant low rate DV) manifesting higher cognitive status scores than Clusters 2 and 3. A step-wise discriminant function analysis also showed cognitive status to be the only statistically significant predictor of cluster membership. The authors' note that the scientific literature on agitation is fraught with contradictory findings and assert that inconsistencies may be due to differences across studies in problem definition, method of measurement, and sample size. The results are discussed in relation to these methodological issues and clinical implications of the findings.

Excess disability during morning care in nursing home residents with dementia.

Excess disability was examined in 17 nursing home residents with dementia by comparing their performance of morning care tasks under two activities of daily living (ADL) caregiving approaches-a dependence-supportive one under usual care and an independence-supportive one under functional rehabilitation. The results suggest that excess disability in severely cognitively impaired and functionally disabled residents can be reduced by increasing opportunities for independent activity, and substituting nondirective and directive verbal assists for physical assists. Further, the findings indicate that increased independence in ADL can be achieved without increasing disruptive behaviors and can foster appropriate requests for task-related help during caregiving. Functional rehabilitation, however, requires more time than usual care.

Natural history of Streptococcus sanguinis in the oral cavity of infants: evidence for a discrete window of infectivity.

The heterogeneous group of oral bacteria within the sanguinis (sanguis) streptococci comprise members of the indigenous biota of the human oral cavity. While the association of Streptococcus sanguinis with bacterial endocarditis is well described in the literature, S. sanguinis is thought to play a benign, if not a beneficial, role in the oral cavity. Little is known, however, about the natural history of S. sanguinis and its specific relationship with other oral bacteria. As part of a longitudinal study concerning the transmission and acquisition of oral bacteria within mother-infant pairs, we examined the initial acquisition of S. sanguinis and described its colonization relative to tooth emergence and its proportions in plaque and saliva as a function of other biological events, including subsequent colonization with mutans streptococci. A second cohort of infants was recruited to define the taxonomic affiliation of S. sanguinis. We found that the colonization of the S. sanguinis occurs during a discrete "window of infectivity" at a median age of 9 months in the infants. Its colonization is tooth dependent and correlated to the time of tooth emergence; its proportions in saliva increase as new teeth emerge. In addition, early colonization of S. sanguinis and its elevated levels in the oral cavity were correlated to a significant delay in the colonization of mutans streptococci. Underpinning this apparent antagonism between S. sanguinis and mutans streptococci is the observation that after mutans streptococci colonize the infant, the levels of S. sanguinis decrease. Children who do not harbor detectable levels of mutans streptococci have significantly higher levels of S. sanguinis in their saliva than do children colonized with mutans streptococci. Collectively, these findings suggest that the colonization of S. sanguinis may influence the subsequent colonization of mutans streptococci, and this in turn may suggest several ecological approaches toward controlling dental caries.

Validity and coverage of estimates of relative accuracy.

PURPOSE: Studies comparing test accuracy often restrict the confirmation procedure to subjects classified as positive by either test. Relative sensitivity (RSN) and relative false-positive rate (RFP) are two estimable comparative measures of accuracy. This article evaluates the influence of sample size, disease prevalence, and test accuracy on the validity of point estimates of RSN and RFP, and on the coverage of their confidence intervals (CI). METHODS: For each combination of sample size, disease prevalence, test accuracy, and interdependence between tests 1,000 samples were generated using computer simulations. The percent bias in the RSN and RFP estimates was measured by comparing the means of the 1,000 values computed in each simulation (log-transformed) with their theoretical values. Coverage of the estimated CI was measured by computing the proportion that actually included the theoretical values. Application of these methods was illustrated with data from a study comparing mammography and physical examination in screening for breast cancer. RESULTS: RSN estimates were valid if the true number of diseased cases exceeded 30, and RFP estimates were valid if the number of nondiseased subjects exceeded 200. When the numbers of diseased and nondiseased subjects exceeded 150 each, the 95% CI of RSN and RFP provided adequate coverage of the parameters (95 +/- 2%). CONCLUSION: Sample size is the most important variable for the validity and coverage of RSN and RFP estimates. For small samples, validity and coverage of RSN and RFP also depend on the accuracy of each test and on the degree of interdependence between the tests.

Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care.

OBJECTIVE: The purposes of this study were (1) to determine the extent to which tobacco exposure assessment and new patient education methods, derived from a meta-analysis and the Agency for Health Care Policy and Research guideline recommendations, could be provided routinely by trained Medicaid maternity care staff members and (2) to document the behavioral impact of these interventions among pregnant smokers. STUDY DESIGN: After 265 pregnant smokers were assigned at their first visit to an experimental group (n = 139) or a control group (n = 126), they received standardized risk information and were advised to quit smoking. The experimental group also received evidence-based patient education methods, including the videocassette Commit to Quit During and After Pregnancy, the publication A Pregnant Woman's Guide to Quit Smoking, and a brief counseling session. Self-report and saliva cotinine assessments of tobacco exposure were performed at baseline and at the end of pregnancy. RESULTS: A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%). CONCLUSIONS: The application of principles of organizational development and quality improvement at the management and clinical practice levels and the delivery of evidence-based health education methods by trained prenatal care providers significantly increased smoking cessation rates among pregnant Medicaid recipients.

Agitation in nursing home residents: the role of gender and social context.

We investigated the relationship among gender of resident, staff social interaction, and agitation in 46 (31 male and 15 female) nursing home residents with clinically significant agitation. Direct observations were conducted of resident behaviors and environmental contextual events using a computer-assisted, real-time observational system. The system recorded frequency, duration, and temporal sequencing of events. Results show that female residents displayed almost three times the amount of agitation as male residents (35% vs. 13% of total observation time, respectively), although men in the study were more likely to receive psychoactive drugs for their agitation. Staff spent similar amounts of time verbally interacting and touching male and female residents. Sequential analyses were conducted to examine the likelihood of staff verbal and touch interactions both preceding and following resident agitation using Bakeman and Quera's (1995) SDIS-GSEQ program. Results suggest that staff touch and verbal interaction elicit agitation in a significant proportion of residents. Once agitation occurs, staff were likely to respond by interacting verbally, but not physically, with the resident.

Improving morning care routines of nursing home residents with dementia.

OBJECTIVES: This study examined the effectiveness of a behavioral rehabilitation intervention for improving the performance of morning care activities of daily living (ADL) of nursing home residents with dementia. DESIGN: Participants and their caregivers were observed for 5 days each under conditions of Usual Care (naturalistic) and Skill Elicitation (intervention), and for 15 days under Habit Training (intervention follow-up). Observations involved the ADL categories of DRESSING, OTHER ADL, and NO ADL. A 3 x 3 design (condition x ADL category) was used. SETTING: Observations occurred in five proprietary nursing homes in Pittsburgh, Pennsylvania. PARTICIPANTS: The participants were 58 women and 26 men, mean age 82 years (range = 64-97, SD = 6.3), with Probable Alzheimer 's disease (AD) (n = 19) and Possible AD (n = 65), with a mean MMSE score of 6.07. INTERVENTION: Condition 1, Usual Care, was the naturalistic caregiving condition. Condition 2, Skill Elicitation, consisted of an individualized behavioral rehabilitation intervention designed to identify and elicit retained ADL skills. Under Condition 3, Habit Training, the behavioral rehabilitation intervention was continued to reinforce and solidify retained skills and to facilitate further functional gains. MEASUREMENTS: A computer-assisted data collection system was used to document in real-time the assists used by caregivers, the participants' ADL performance, and the participants' responses to caregiving, including disruptive behavior. RESULTS: Compared with Usual Care, during Skill Elicitation participants increased the proportion of time engaged in nonassisted and assisted dressing significantly and increased their overall participation in ADL, with a concomitant significant decrease in disruptive behavior. These functional gains were demonstrated within 5 days of initiating the behavioral rehabilitation intervention and were maintained for 3 weeks during Habit Training. Physical assists were provided for significantly smaller proportions of a morning care session during Skill Elicitation and Habit Training compared with Usual Care. CONCLUSIONS: Even very severely cognitively impaired and functionally disabled nursing home residents can respond to a systematically implemented behavioral rehabilitation intervention. Their rapid response to this intervention suggests that it is alleviating excess disabilities brought on by care patterns rather than retraining ADL task performance. Residents with dementia benefit from behavioral rehabilitation by becoming more appropriately involved in their care and being less disruptive. However, behavioral rehabilitative care takes considerably more time than usual care.

Regression modeling strategies: an illustrative case study from medical rehabilitation outcomes research.

The practice of outcomes research is growing in all segments of the health care industry, yet few practitioners and researchers are prepared to deal with the completion of statistical analyses that characterize the new focus on results. This article discusses basic model formulation and interpretation. It also encourages the use of statistical models that study the simultaneous effects of many variables on an outcome and gives examples of relationships among variables that are not simple and linear. The methods are illustrated with a dataset consisting of stroke rehabilitation inpatients discharged during a 3-year period with an admission date that is within 1 year after stroke.

Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial.

CONTEXT: Urinary incontinence is a common condition caused by many factors with several treatment options. OBJECTIVE: To compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the treatment of urge and mixed urinary incontinence in older community-dwelling women. DESIGN: Randomized placebo-controlled trial conducted from 1989 to 1995. SETTING: University-based outpatient geriatric medicine clinic. PATIENTS: A volunteer sample of 197 women aged 55 to 92 years with urge urinary incontinence or mixed incontinence with urge as the predominant pattern. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and not have dementia. INTERVENTION: Subjects were randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment (with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition. MAIN OUTCOME MEASURES: Reduction in the frequency of incontinent episodes as determined by bladder diaries, and patients' perceptions of improvement and their comfort and satisfaction with treatment. RESULTS: For all 3 treatment groups, reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter. Behavioral treatment, which yielded a mean 80.7% reduction of incontinence episodes, was significantly more effective than drug treatment (mean 68.5% reduction; P=.04) and both were more effective than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009, respectively). Patient-perceived improvement was greatest for behavioral treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment and placebo, respectively). Only 14.0% of patients receiving behavioral treatment wanted to change to another treatment vs 75.5% in each of the other groups. CONCLUSION: Behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence.

Association rules and data mining in hospital infection control and public health surveillance.

OBJECTIVES: The authors consider the problem of identifying new, unexpected, and interesting patterns in hospital infection control and public health surveillance data and present a new data analysis process and system based on association rules to address this problem. DESIGN: The authors first illustrate the need for automated pattern discovery and data mining in hospital infection control and public health surveillance. Next, they define association rules, explain how those rules can be used in surveillance, and present a novel process and system--the Data Mining Surveillance System (DMSS)--that utilize association rules to identify new and interesting patterns in surveillance data. RESULTS: Experimental results were obtained using DMSS to analyze Pseudomonas aeruginosa infection control data collected over one year (1996) at University of Alabama at Birmingham Hospital. Experiments using one-, three-, and six-month time partitions yielded 34, 57, and 28 statistically significant events, respectively. Although not all statistically significant events are clinically significant, a subset of events generated in each analysis indicated potentially significant shifts in the occurrence of infection or antimicrobial resistance patterns of P. aeruginosa. CONCLUSION: The new process and system are efficient and effective in identifying new, unexpected, and interesting patterns in surveillance data. The clinical relevance and utility of this process await the results of prospective studies currently in progress.

The use of an enteral expert system in the prescription of enteral formulas in a university hospital.

A personal computer-based expert system has been developed for the prescription of enteral formulas based on patient-need characteristics. Two hundred twelve inpatients in a university hospital setting were prospectively evaluated to compare the identity and cost of the enteral formula prescribed by the expert system with the identity and cost of the enteral formula prescribed by the ward team. Two hundred seven patients had complete data to allow analysis. There was a mean cost savings (+/-SD) of $1.18 +/- 7.69/d for each patient using the expert system compared with the MD-prescribed formula (P = 0.023). We project that the use of this program would save $27,564/y in our hospital (an average of 23,360 patient/days of enteral feeding per year). We conclude that the use of an expert system can be cost-effective in the prescription of enteral formulas for hospitalized patients.

Environmental "white noise": an intervention for verbally agitated nursing home residents.

This study presents preliminary data on the efficacy of two environmental "white noise" audiotapes for the treatment of verbal agitation in severely demented nursing home residents. The researchers employed a computer-assisted real-time observational system to assess both the frequency of verbal agitation and the actual use of the intervention on the nursing units (treatment fidelity). Intervention by nurse aides (NAs) on the unit was preceded by a researcher-controlled functional analysis phase that provided information regarding which of the two audiotapes would be most effective for individual residents. Results indicate a 23% reduction in verbal agitation with this individualized treatment strategy on the nursing units. These results were obtained even though treatment fidelity data showed that the audiotapes were used during only 51% of the observations. The authors discuss the need for formal staff management procedures for increasing staff compliance with treatment regimens.

Lack of independent relationships between left ventricular mass and cardiovascular reactivity to physical and psychological stress in the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

The objective of this study was to determine whether exaggerated blood pressure (BP) reactivity to stress and psychosocial characteristics are related to left ventricular mass (LVM) in a large cohort of young adults. Analyses were conducted with 3,742 participants of the CARDIA study (945 white men, 1,024 white women, 781 black men, and 992 black women), evaluated in 1990 to 1091 with echocardiographic measurement of LVM. Analyses were stratified by gender and race. The relationships of LVM/height2.7 and cardiovascular reactivity to physical and psychological stressors (treadmill exercise, cold pressor, video game, and star-tracing tasks), were examined in both univariate and multivariate analyses adjusting for baseline BP, weight, and other relevant biobehavioral variables. The relationships between LVM and several psychosocial characteristics (hostility, anger suppression, anxiety, depressive symptoms, and education) were also assessed. Systolic blood pressure (SBP) reactivity to exercise was significantly related to LVM in black and white men; LVM was 10% greater among white men with exaggerated (upper quintile) peak exercise SBP than among other white men. SBP reactivity to the cold pressor test was related to LVM in all race/gender groups, although the relationship remained significant only among white men and women in the multivariate analysis. Diastolic blood pressure (DBP) reactivity to the video game was related to LVM only among black men in adjusted analyses. After adjusting for resting BP, weight, and other covariates in linear multiple regression models, SBP reactivity to exercise explained only 3% of the variance in LVM among white men. Otherwise, reactivity to other stressors or psychosocial variables accounted for no more than 1% of the variance in LVM. It was concluded that among a cohort of young adults, blood pressure reactivity to physical and mental stressors did not add substantially to the prediction of LVM when resting BP, weight, and other covariates were taken into account.

Nocturnal enuresis in community-dwelling older adults.

OBJECTIVE: To investigate the prevalence and characteristics of nocturnal enuresis in community-dwelling older adults and to identify potential predisposing variables. DESIGN: Interview survey. SETTING: Five rural counties in northwestern Pennsylvania. PARTICIPANTS: Subjects were 3884 community-dwelling older adults aged 65 to 79 years who volunteered for a health promotion demonstration. MEASUREMENTS: The dependent variable was self-reported accidental loss of urine during sleep. Independent variables included demographic variables, self-reported disease history and symptomatology, and standardized screening instruments for depression (CES-D), dementia (MMSE), and functional status (ADLs). MAIN RESULTS: Prevalence of nocturnal enuresis was 2.1%, and was significantly higher among women (2.9%) compared with men (1.0%; P < .0001). Compared with subjects with daytime incontinence only, those with nocturnal enuresis reported greater severity and impact of incontinence on several parameters. Enuretics were more likely to have received treatment; treatment outcome, however, was significantly less successful. In univariate analyses, enuresis was significantly associated with symptoms of congestive heart failure (CHF), impairment in activities of daily living, depression, and use of sleep medications at least once per week. In stepwise logistic regression modeling, two symptoms of congestive heart failure and regular use of sleep medication entered the model. CONCLUSIONS: Nocturnal enuresis appears to be uncommon among older adults, but it may be associated with poorer therapeutic outcomes compared with the more common forms of daytime incontinence. The findings are consistent with the hypothesis that daytime fluid accumulation followed at night by mobilization of excess fluid is a contributor to enuresis in older adults.

Correlates and predictors of weight loss in young adults: the CARDIA study.

OBJECTIVE: To determine associations of sociodemographic characteristics, behaviors, attitudes and medical factors with weight loss in a population-based biracial cohort of young adults. DESIGN: Two-year longitudinal observation study. SUBJECTS: 4278 black and white men and women aged 18-30 years in 1985-1986. MEASUREMENTS: Weight, height, education, income, subscapular skinfold thickness, waist and hip circumferences, medical history, smoking, physical activity, dietary energy, fat and alcohol intake, physical fitness measured by treadmill testing, self-reported dieting, history of weight loss and regain, perception of body size and belief in health consequences of overweight. RESULTS: Weight loss, defined as reduction of 5% or more of baseline weight, occurred in 8.9% of the cohort, ranging from 4.9% among white men who were not overweight at baseline to 21.5% among white women who were overweight. Weight loss was more common in women than men and in overweight white women than overweight black women. Although findings differed among the four race-sex groups, weight loss was generally associated with greater baseline fatness, lower baseline physical fitness level, self-perception of being overweight, dieting and previous weight loss and regain. Greater baseline fatness, a perception of being overweight and dieting were also associated with weight gain. Among the overweight, low baseline fitness and an increase in physical activity were the factors most consistently associated with weight loss. CONCLUSION: Weight loss in young adults varies by race, sex and body weight and is associated with a variety of behaviors and attitudes, some of which are also associated with weight gain and, thus, may be associated with weight fluctuation.

Urinary incontinence during pregnancy in a racially mixed sample: characteristics and predisposing factors.

The objectives of the study were to assess the prevalence of urinary incontinence symptoms during pregnancy in a racially mixed sample and to identify potential predisposing variables. Five hundred and twenty-three women were interviewed in the hospital on postpartum day 2 or 3 and by telephone at 6-week follow-up. A significantly larger proportion of white women reported accidental loss of urine than did black women (62.6% vs. 46.4%; P < 0.01). A breakdown by type of incontinence indicated that the race effect was largely attributable to the significantly higher prevalence of the symptom of stress incontinence among white women (P < 0.0001). In stepwise logistic regression modeling, previous incontinence, education level, parity and nocturia were selected as the strongest predictors of incontinence in white women. Attendance at childbirth classes was the only predictor of incontinence for black women. The results raise the possibility that higher rates of incontinence among white women might be due to differences in the pelvic floor.

Comparison of M-mode and two-dimensional echocardiographic algorithms used to estimate left ventricular mass: the Coronary Artery Risk Development in Young Adults Study.

Left ventricular (LV) mass as measured from M-mode echocardiography has been shown to be an important predictor of subsequent cardiovascular morbidity and death. Investigators have debated the advantages of LV mass calculations derived from M-mode versus various two-dimensional (2D) echocardiographic algorithms. The purpose of this study was to compare measurements of LV mass made from M-mode and 2D echocardiographic formulas in 325 healthy young adults of the Coronary Artery Risk Development in Young Adults cohort. M-mode LV mass was calculated according to a necropsy-validated formula, whereas 2D LV mass was calculated according to two established algorithms (i.e., the biplane Simpson and truncated ellipsoid methods). LV mass derived from M-mode echocardiography was 162.7 +/- 52 gm (mean +/- SD). Mean (+/- SD) LV mass derived from 2D echocardiographic measurements were as follows: with the biplane Simpson method (four-chamber view), 164.2 +/- 42 gm; with the biplane Simpson method (two-chamber view), 159.8 +/- 44 gm; with the truncated ellipsoid method (four-chamber view), 139.8 +/- 37 gm; and with the truncated ellipsoid method (two-chamber view), 143.1 +/- 38 gm. Correlations between M-mode and 2D methods ranged from 0.75 to 0.81 (p < 0.0001 for each comparison), and correlations between 2D methods were all greater than 0.90. This study has demonstrated that measurements of LV mass calculated from M-mode and 2D formulas correlate well with each other. Nonetheless, LV mass calculated from the truncated ellipsoid formula averages approximately 20 gm less than that calculated from the 2D biplane Simpson or M-mode echocardiographic formulas. These systematic differences in calculated values for LV mass must be taken into account when choosing an LV mass algorithm for use in cross-sectional and serial studies.

Nurses' acceptance of behavioral treatments and pharmacotherapy for behavioral disturbances in older adults.

Behavioral disturbances are common in elderly individuals, particularly in those suffering from dementia. Nurses are called on to manage these problem behaviors both in the nursing home and through home health care. There has been growing interest in nonpharmacological interventions for these problems, most notably behavioral therapies. However, until recently, no information was available regarding the acceptance by health care professionals on the use of these treatments with elderly individuals. The purpose of this study was to assess geriatric nurses' acceptance of two behavioral treatments (differential reinforcement of incompatible behavior and time-out from positive reinforcement) and the most commonly used treatment at this time, pharmacotherapy. Nurses were asked to read a clinical case vignette and three treatment descriptions, rating the treatments with Kazdin's Treatment Evaluation Inventory. Results show that both behavioral treatments, including a mildly aversive treatment (time-out) were rated more positively than pharmacotherapy. Nurses modified their ratings in response to described differences in the patient's cognitive functioning and place of residence. Most interesting, acceptability ratings were influenced by characteristics of nurse raters, including the nurses' educational background and the amount of contact with geriatric patients.