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PubMed2001

[Comparative hospital tours: visiting the oasis of psychiatry].

AIM: Currently, financial sponsors and Government officials of the relevant ministries responsible for the German health care system request comparative length-of-stay figures in hospitals as indicators of efficacy of inpatient treatment. In psychiatry such comparisons are considered doubtful because of the heterogeneity of patients in different hospitals. This study compares the length of stay in eight German psychiatric hospitals accounting for individual as well as organisational characteristics. METHODS SAMPLE: 27,792 patient records according to the DGPPN-BADO (the standardized psychiatric assessment and discharge battery in Germany) from eight hospitals with a total of 135 wards. STATISTICAL ANALYSIS: Variance components modelling with random effects using three levels (patients, wards, hospitals). RESULTS: After adjustment for patient and organisational characteristics, there were no significant differences in the average length of stay between the eight hospitals. CONCLUSIONS: Hospital comparisons of quality of care require a multilevel approach. Based on our results further comparisons and implementation of quality improvements in inpatient psychiatry should focus on the ward level.

Germany↗
PubMed2001

Depressive symptomatology in middle-aged and older married couples: a dyadic analysis.

OBJECTIVES: Depressive symptomatology has been frequently conceptualized as an individual matter, but social contextual models argue that symptom levels are likely to covary in close relationships. The present study investigated correlation between spouses' depressive symptomatology in middle-aged and older married couples, the influence of gender and race/ethnicity in predicting variability in symptom level, and the importance of individual-level covariates (education, health, and age) and couple-level covariates (household income and net worth). METHODS: Results were based on secondary analysis of Wave 1 interviews with White, Black, and Mexican American married couples (N = 5,423) from the Health and Retirement Study (HRS) and the Study of Asset and Health Dynamics Among the Oldest Old (AHEAD). Dyadic data from husbands and wives were analyzed with multilevel modeling. RESULTS: Husbands' and wives' depressive symptoms were moderately correlated, gender and race/ethnicity (and their interaction) predicted depressive symptoms, and both individual-level and couple-level characteristics were significant covariates. Similarities as well as differences are noted between the HRS and AHEAD results. DISCUSSION: Results highlight the importance of dyadic data and multilevel models for understanding depressive symptomatology in married couples. The influence of race/ethnicity merits greater attention in future research. Differences in findings between HRS and AHEAD suggest life-course, cohort, or methodological influences.

Aged↗
PubMed1993

Generation, ethnicity, and marriage: historical patterns in the northern United States.

Immigration was a prominent feature of American life during the early decades of the twentieth century. About 40% of the white population was of foreign birth or parentage, and immigrants were increasingly from diverse national origins. Using data from the Public Use Microdata Sample of the 1910 U.S. Census, we examine generational and ethnic differences in marital timing. The analysis reveals a striking pattern of delayed marriage among native whites with foreign parents, but marked ethnic variation in the extent of marriage delay within the second generation. We hypothesize that locational factors, especially diverse economic opportunities, were important in shaping this marriage pattern. Separate multilevel analyses are conducted for females and for males living in urban and in rural places. Although significant effects for a variety of contextual factors are found, generational and ethnic differences in nuptial timing persist in multivariate models.

Age Factors↗
PubMed2026

Analysis of tuberculosis and multiple diseases as co-morbidities: a narrative review.

BACKGROUND: Tuberculosis (TB) remains the leading cause of death from infectious diseases worldwide, and its control is increasingly complicated by chronic comorbidities. Diabetes mellitus (DM), human immunodeficiency virus (HIV) infection, chronic obstructive pulmonary disease (COPD), and lung cancer (LC) substantially affect TB susceptibility, diagnosis, treatment, and prognosis. METHODS: This narrative review summarizes evidence on the interactions between TB and DM, HIV infection, COPD, and LC. Relevant literature was identified through PubMed, Web of Science, and World Health Organization publications, focusing on studies published between 2001 and 2025. Priority was given to peer-reviewed original studies and reviews addressing immune mechanisms, diagnosis, and treatment. RESULTS: DM increases TB risk by impairing innate and adaptive immunity and complicates prevention, diagnosis, and treatment. HIV-1 weakens antimycobacterial defense through lymphocyte depletion, macrophage dysfunction, granuloma instability, and immune exhaustion, markedly increasing susceptibility to active TB. TB and COPD mutually aggravate pulmonary inflammation, oxidative stress, and structural lung damage, contributing to poor respiratory outcomes. Mycobacterium tuberculosis(M.tb) infection may also be associated with LC development through chronic inflammation, oxidative stress-related genomic instability, and oncogenic signaling. Overall, these comorbidities increase diagnostic difficulty, therapeutic complexity, and the risk of adverse outcomes. CONCLUSIONS: TB associated comorbidities remain a major challenge to global TB control. Understanding these interactions may support bidirectional screening, risk stratification, and integrated management. Although these conditions share immune dysregulation, chronic inflammation, and oxidative stress, they differ in dominant mechanisms, diagnostic challenges, and treatment priorities. Future research should prioritize biomarker discovery, mechanistic clarification, and multilevel prevention and control strategies.

Humans↗
PubMed2004

Biomechanical analysis of transpedicular screw fixation in the subaxial cervical spine.

STUDY DESIGN: An in vitro biomechanical study to compare 2 different dorsal screw fixation techniques in the cervical spine with respect to primary stability and stability after cyclic loading. OBJECTIVES: To investigate if the biomechanical stability is better in pedicle screw or in lateral mass fixation. SUMMARY OF BACKGROUND DATA: In patients with poor bone quality who require multisegmental fixations, the current dorsal stabilization procedures in the subaxial cervical spine using lateral mass screws are often insufficient. Cervical pedicle screw fixation has been suggested as an alternative procedure, but there are still limited data available on the biomechanical differences between pedicle screw and lateral mass fixation. METHODS: A severe multilevel discoligamentous instability was created in 8 human cervical spine specimens (C2-C7). Dorsal stabilization was performed with the assistance of computer navigation (SurgiGate, Medivison, Switzerland) using either lateral mass or pedicle screw fixation. In the first part of the study, primary stability was measured by means of a multidirectional flexibility test. Then, specimens were divided into 2 groups, randomized for bone mineral density. Cyclic loading was applied with sinusoidal loads in flexion/extension (1000 cycles, +/-1.5 Nm, 0.1 Hz). Mechanical behavior of the specimens was determined by a flexibility test before and after the application of cyclic loads. Data analysis was performed by calculating the ranges of motion, and statistical differences were determined with the t test for group comparison. RESULTS: Pedicle screw fixation showed a significantly higher stability in lateral bending (pedicle screw range of motion 0.86 +/- 0.31 degrees; lateral mass range of motion 1.43 +/- 0.62 degrees; P = 0.037). No significant differences were seen in flexion/extension and axial rotation. After cyclic loading, the decrease in stability was less with pedicle screw fixation in all load directions. Differences in the decrease of stability were statistically significant in flexion/extension (pedicle screw 95.4 +/- 9.4%; lateral mass 70.5 +/- 9.8%; P = 0.010) and lateral bending (pedicle screw 105.3 +/- 5.0%; lateral mass 84.2 +/- 13.6%; P = 0.046), whereas there was no significant difference in axial rotation. CONCLUSIONS: The major finding of the current study was the higher stability of pedicle screws over lateral mass fixation with respect to primary stability and stability after cyclic loading. From a biomechanical point of view the use of pedicle screws in the subaxial cervical spine seems justified in patients with poor bone quality and need for multisegmental fixation.

Adult↗
PubMed2003

School functioning and violent behavior among young adolescents: a contextual analysis.

This paper examines associations between overall school functioning and frequency of violent behaviors among young adolescents (ages 10-14). The sample included 16 middle schools participating in an unrelated intervention study (on nutrition) in Minneapolis, Minnesota. A School Functioning Index, developed to characterize schools' overall stability, performance and demographics, was constructed using data from public archives and school administrator surveys. Data on violent behaviors and other variables were collected in student surveys in fall 1998 and spring 1999. We used multilevel modeling to assess the effect of school functioning on violent behavior after adjusting for known individual-level covariates of violent behaviors. We found an interaction between school functioning (group-level variable) and expectations for future education (individual-level variable). Among students who reported expectations of completing a college degree (71% of the sample), positive school functioning was negatively associated with violent behaviors. Among students that reported expectations of completing less than a college degree, no association was found between school functioning and violent behaviors. These results support earlier work suggesting that objectively measured school characteristics are associated with students' violent behaviors even after accounting for individual-level factors and also identify a subgroup of students for whom school detachment may be an issue.

Adolescent↗
PubMed2006

Physical activity and strength of the femoral neck during the adolescent growth spurt: a longitudinal analysis.

Loading of the femoral neck (FN) is dominated by bending and compressive stresses. We hypothesize that adaptation of the FN to physical activity would be manifested in the cross-sectional area (CSA) and section modulus (Z) of bone, indices of axial and bending strength, respectively. We investigated the influence of physical activity on bone strength during adolescence using 7 years of longitudinal data from 109 boys and 121 girls from the Saskatchewan Paediatric Bone and Mineral Accrual Study (PBMAS). Physical activity data (PAC-Q physical activity inventory) and anthropometric measurements were taken every 6 months and DXA bone scans were measured annually (Hologic QDR2000, array mode). We applied hip structural analysis to derive strength and geometric indices of the femoral neck using DXA scans. To control for maturation, we determined a biological maturity age defined as years from age at peak height velocity (APHV). To account for the repeated measures within individual nature of longitudinal data, multilevel random effects regression analyses were used to analyze the data. When biological maturity age and body size (height and weight) were controlled, in both boys and girls, physical activity was a significant positive independent predictor of CSA and Z of the narrow region of the femoral neck (P < 0.05). There was no independent effect of physical activity on the subperiosteal width of the femoral neck. When leg length and leg lean mass were introduced into the random effects models to control for size and muscle mass of the leg (instead of height and weight), all significant effects of physical activity disappeared. Even among adolescents engaged in normal levels of physical activity, the statistically significant relationship between physical activity and indices of bone strength demonstrate that modifiable lifestyle factors like exercise play an important role in optimizing bone strength during the growing years. Physical activity differences were explained by the interdependence between activity and lean mass considerations. Physical activity is important for optimal development of bone strength.

Adolescent↗
PubMed1994

"How can we know the dancer from the dance?" The analysis of a five-year-old girl.

How the analyst and the patient shape the analysis is a complex matter varying with the stage of the analysis and the individual characteristics of each patient and analyst. Examining analytic hours from the beginning, middle, and end of a five-through-seven-year-old girl's treatment suggests an intricate pattern evolving from observing and learning toward elaborating a free-ranging, creative, multilevel interplay of internal dialogues and affects.

Child↗
PubMed2004

Teenagers' use of sexual health services: perceived need, knowledge and ability to access.

INTRODUCTION: An individual teenager's use of services may depend on perceived need, on knowledge of sexual health and local services, and on ability to access. This paper presents the first UK large-scale quantitative analysis of these factors, comparing those who use services with those who do not. METHODS: 15/16-year-olds (n = 5747) were questioned about their use of sexual health services in the SHARE trial of a school sex education programme in 25 schools in Lothian and Tayside, Scotland, UK. Multilevel statistical models examined the role of different factors on service use. RESULTS: One-third of teenagers had used a service, and use was strongly related to sexual experience. In addition, some family influences and being a school leaver were associated with service use, although we found no evidence for class, ethnic or religious barriers to use. Proximity to specialist clinics was linked with greater use, while low spending money and high parental monitoring were associated with less use. Teenagers with better knowledge, who rated their school sex education as effective, who were comfortable talking about sex and who had discussed contraception with peers were more likely to have used services. Differences in use relating to sexual experience, knowledge, feeling comfortable talking about sex and talking with peers helped to explain gender differences in service uptake. CONCLUSION: There is potential to influence service use through better knowledge and confidence imparted through school sex education, and by improving the links between services and schools.

Adolescent↗
PubMed1976

18. Uniform cost accounting in long-term care.

Uniform cost data are essential for managing health services, establishing billing and reimbursement rates, and measuring effectiveness and impact. Although it is especially difficult in the case of long-term health care to develop standard cost accounting procedures because of the varied configurations of inpatient, intermediate, and ambulatory services, the overall approaches to cost accounting and its content can be made more uniform. With this purpose in mind, a general model of cost accounting is presented for a multilevel program of long-term services, together with a special method for ambulatory services using "hours accounted for" as the basic measure.

Ambulatory Care↗
PubMed2002

Why are women missing from outpatient cardiac rehabilitation programs? A review of multilevel factors affecting referral, enrollment, and completion.

OBJECTIVES: The objectives of this paper are to (1) systematically review the evidence for patient, provider, and programmatic factors that may influence women's referral to, enrollment in, and completion of outpatient cardiac rehabilitation and (2) make empirically based recommendations for future women's health research. METHODS: Using a defined inclusion/exclusion criteria, this review involved a systematic review and description analysis of the published peer-review literature. RESULTS: The review yielded 23 studies described in 25 publications. Although gaps in the knowledge base exist and several methodological concerns limit the evidence, this body of work suggests that age, personal resources, low rates of physician referral, and weak recommendations to participate in rehabilitation may explain why women are missing from this life-saving intervention. CONCLUSIONS: Practitioners engaged in the care of eligible cardiac patients should be aware of the evidence for the effectiveness of cardiac rehabilitation, and researchers should examine programmatic and provider factors that affect women's participation.

Age Factors↗
PubMed2005

The transmission of stress to grafted bone inside a titanium mesh cage used in anterior column reconstruction after total spondylectomy: a finite-element analysis.

STUDY DESIGN: A finite-element study of posterior alone or anterior/posterior combined instrumentation following total spondylectomy and replacement with a titanium mesh cage used as an anterior strut. OBJECTIVES: To compare the effect of posterior instrumentation versus anterior/posterior instrumentation on transmission of the stress to grafted bone inside a titanium mesh cage following total spondylectomy. SUMMARY OF BACKGROUND DATA: The most recent reconstruction techniques following total spondylectomy for malignant spinal tumor include a titanium mesh cage filled with autologous bone as an anterior strut. The need for additional anterior instrumentation with posterior pedicle screws and rods is controversial. Transmission of the mechanical stress to grafted bone inside a titanium mesh cage is important for fusion and remodeling. To our knowledge, there are no published reports comparing the load-sharing properties of the different reconstruction methods following total spondylectomy. METHODS: A 3-dimensional finite-element model of the reconstructed spine (T10-L4) following total spondylectomy at T12 was constructed. A Harms titanium mesh cage (DePuy Spine, Raynham, MA) was positioned as an anterior replacement, and 3 types of the reconstruction methods were compared: (1) multilevel posterior instrumentation (MPI) (i.e., posterior pedicle screws and rods at T10-L2 without anterior instrumentation); (2) MPI with anterior instrumentation (MPAI) (i.e., MPAI [Kaneda SR; DePuy Spine] at T11-L1); and (3) short posterior and anterior instrumentation (SPAI) (i.e., posterior pedicle screws and rods with anterior instrumentation at T11-L1). The mechanical energy stress distribution exerted inside the titanium mesh cage was evaluated and compared by finite-element analysis for the 3 different reconstruction methods. Simulated forces were applied to give axial compression, flexion, extension, and lateral bending. RESULTS: In flexion mode, the energy stress distribution in MPI was higher than 3.0 x 10 MPa in 73.0% of the total volume inside the titanium mesh cage, while 38.0% in MPAI, and 43.3% in SPAI. In axial compression and extension modes, there were no remarkable differences for each reconstruction method. In left-bending mode, there was little stress energy in the cancellous bone inside the titanium mesh cage in MPAI and SPAI. CONCLUSIONS: This experiment shows that from the viewpoint of stress shielding, the reconstruction method, using additional anterior instrumentation with posterior pedicle screws (MPAI and SPAI), stress shields the cancellous bone inside the titanium mesh cage to a higher degree than does the system using posterior pedicle screw fixation alone (MPI). Thus, a reconstruction method with no anterior fixation should be better at allowing stress for remodeling of the bone graft inside the titanium mesh cage.

Aged, 80 and over↗
PubMed1988

Combined aortofemoral and extended deep femoral artery reconstruction. Functional results and predictors of need for distal bypass.

In patients with combined aortoiliac and femoropopliteal occlusive disease, severe involvement of the deep femoral artery (DFA) has often been considered an indication for simultaneous aortofemoral and femorodistal bypass grafting. In 73 patients (87 limbs) with multilevel disease, extended DFA reconstruction was performed with aortofemoral bypass. Five-year actuarial patency of the reconstructions and overall five-year actuarial limb salvage were 62.2% and 60.2%, respectively. Of 20 variables tested, four were significantly associated with the functional outcome of the procedures. Multivariate analysis identified two factors as predictive of outcome independently from other variables: preoperative ankle-brachial pressure index and angiographic status of the below-knee popliteal artery. However, in case of reoperation for occluded aortofemoral graft, these factors lost their validity. Extended DFA reconstruction is a valuable and durable procedure able to provide an adequate outflow and distal perfusion. Careful judgment in each clinical situation will aid in selecting a small group of patients in which simultaneous femorodistal bypass is required.

Aged↗
PubMed2006

Higher levels of pain readiness to change and more positive affect reduce pain reports--a weekly assessment study on arthritis patients.

The objective of the study was to analyze the relationships between Pain Readiness to Change, weekly measures of positive and negative affect and pain over eight subsequent weeks in patients with rheumatoid arthritis (RA). Factor analysis based on data from three different samples of patients with rheumatic diseases and other chronic pain conditions suggested a three factor solution for the Norwegian version of the Pain Stages of Change questionnaire (PSOCQ) representing Precontemplation, Contemplation, and Action/Maintenance (ACT) stages from the original Transtheoretical Model. Multilevel analyses on the weekly assessed data from a sub sample of 40 patients with RA revealed that higher levels of Pain Readiness to Change represented by high ACT scores were associated with more positive affect from week to week while no association was found between Readiness to Change and weekly pain. However, there was an interaction effect between Pain Readiness to Change and weekly positive affect on weekly pain, indicating that those persons having a higher level of Readiness to Change reported less pain in weeks when they also experienced increased positive affect. This may imply that a combination of cognitive factors and positive affect is most effective in relation to pain reduction. Results encourage continued investigation of apparent interactions between chronic pain, affect, and pain self-management.

Adaptation, Psychological↗
PubMed2004

Pediatric spine fractures: a review of 137 hospital admissions.

OBJECTIVE: The anatomy and biomechanics of the growing spine produce failure patterns different from those in adults. Spinal injury in the pediatric patient is a concern as prevention of further neurologic damage and deformity and the good potential for recovery make timely identification and appropriate treatment of such injury critical. A retrospective clinical case series was conducted to present data from a large series of pediatric patients with spine injuries from a single regional trauma center. METHODS: One hundred thirty-seven children with spine injuries were seen over 10 years and were divided into three age groups: 0-9, 10-14, and 15-17 years. Analysis of variance and chi2 were used to analyze differences between groups. RESULTS: There were 36 patients aged 0-9, 49 aged 10-14, and 52 aged 15-17. Spine injury incidence increased with age. Motor vehicular accidents were the most common cause in this series. There were 36% cervical, 34% thoracic, 29% lumbar, 34% multilevel contiguous, and 7% multilevel noncontiguous involvement. Nineteen percent had spinal cord injury. Thirteen of 21 complete neurologic injuries and all 3 incomplete injuries improved. Cord injury was more common in the 0-9 age group. Four of five patients with spinal cord injury without radiographic abnormality (SCIWORA) were in the 0-9 age group and had complete neurologic injuries. Young children with cervical injuries were more likely to die than older children. Fifty-three percent had associated injuries. Eighteen percent underwent decompression, fusion, and instrumentation. Two patients developed scoliosis. The complication rate in surgical patients was higher than in patients treated nonsurgically and in polytrauma patients. This may be related to the severity of the initial injury. CONCLUSIONS: Our results suggest age-related patterns of injury that differ from previous work. The incidence of cord injury is 20% with higher frequencies in the young child. Potential for neurologic recovery is good. Young children have a higher risk for death than older children. There was no predominance of cervical injuries in the young child. The incidence of SCIWORA was low. Higher complication rates were seen in polytrauma and surgical patients.

Accidents↗
PubMed2004

Behavioral analysis of male rat sexual motivation and performance following acute ethanol treatment.

To characterize the effects of acute ethanol treatment on sexual motivation and performance, 30 male Long-Evans rats were assigned to one of three treatment conditions: saline (n=9), 0.25 g/kg ethanol (n=10), or 1.0 g/kg ethanol (n=11). Males were injected intraperitoneally 30 min before behavioral testing. Male rats were placed in a multilevel testing chamber 5 min prior to the introduction of a receptive female rat and level changes were recorded as an index of sexual motivation. After the female rat was placed in the chamber, standard measures of sexual performance were recorded over three weekly tests. Results indicated that the highest dose of ethanol (1.0 g/kg) increased male rat level-changing behavior compared to the saline group. Although ethanol treatment failed to affect most measures of sexual performance, males administered 1.0 g/kg ethanol had fewer anogenital investigations and had longer postejaculatory intervals (PEIs) compared to control animals. The data from this experiment suggest that ethanol increases rodent sexual motivation but impairs specific parameters of sexual performance.

Animals↗
PubMed2026

Engagement and Retention in Precision Public Health: A Cascade Analysis of Two Cluster Randomized Trials.

INTRODUCTION: When research fails to reach and engage all populations who might benefit from study findings, it can compromise scientific validity and ultimately health equity. Few studies have systematically examined factors driving study engagement through longitudinal intervention research. This project examined sociodemographic, geographic, and structural influences on engagement and attrition across the participation "cascade" (outreach, enrollment, retention) for two large-scale multilevel precision medicine and precision prevention trials for smoking and lung cancer screening. METHODS: Modified Poisson regression models were used to determine the factors associated with study engagement based on sociodemographic and geographical factors at each step in the cascade of participation, from initial outreach through retention at 12 months post-enrollment. Secondary analyses examined the cascade among the subset of patients who had active electronic patient portals and were approached via the portal. RESULTS: A total of 24,366 patients were approached for participation. Race, Social Vulnerability Index (SVI), insurance status, and distance from the study site were significantly associated with engagement at various points in the cascade. Black patients were more likely than White patients to be reached (48.9% vs 47.1%; p = 0.022) and to complete eligibility screening (52.8% vs. 38.4%; p < 0.001), but less likely to consent to participate (56.7% vs 69.8%; p < 0.001) and complete genetic testing (58.5% vs. 69.8%; p = 0.003). Patterns of engagement through electronic patient portal versus non-electronic recruitment channels also differed by race- and place-based factors, with Black patients being less likely than White patients to respond in the portal (8.8% vs 15.5%; p < 0.001), and patients who reside farther from the study site being more likely to respond in the portal compared to those who live closer (14.9% vs 12.5%; p < 0.001). CONCLUSIONS: These findings highlight the need for tailored, stage-specific engagement strategies to ensure representative participation in genomic and behavioral intervention research to advance the integration of genomics into public health practice.

Journal Article↗