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PubMed2005

Exact sample sizes needed to detect dependence in 2 x 3 tables.

Many medical and biological studies entail classifying a number of observations according to two factors, where one has two and the other three possible categories. This is the case of, for example, genetic association studies of complex traits with single-nucleotide polymorphisms (SNPs), where the a priori statistical planning, analysis, and interpretation of results are of critical importance. Here, we present methodology to determine the minimum sample size required to detect dependence in 2 x 3 tables based on Fisher's exact test, assuming that neither of the two margins is fixed and only the grand total N is known in advance. We provide the numerical tools necessary to determine these sample sizes for desired power, significance level, and effect size, where only the computational time can be a limitation for extreme parameter values. These programs can be accessed at . This solution of the sample size problem for an exact test will permit experimentalists to plan efficient sampling designs, determine the extent of statistical support for their hypotheses, and gain insight into the repeatability of their results. We apply this solution to the sample size problem to three empirical studies, and discuss the results with specified power and nominal significance levels.

DNA, Mitochondrial↗
PubMedDate not supplied

Computer-assisted visualization and quantitation of experimental gastric lesions in rats.

INTRODUCTION: Photography is commonly used to evaluate macroscopic morphology of experimental gastric lesions. The conventional methods for quantitation of these lesions tend to be highly subjective, error-prone, and tedious. This study reports a simple and novel method for visualization of experimental gastric lesions by direct scanning of stomach samples and their quantitation by using computer-assisted image analysis. METHODS: Gastric mucosal lesions were produced by indomethacin or ethanol in male Wistar rats. The stomachs were removed, opened along the greater curvature, and washed. The flattened stomach samples were sandwiched within a transparent plastic folder and scanned. The captured image was saved and subjected to lesion quantitation using a freely accessible image analysis program, Scion Image. A macro subroutine was optimized for automation of the entire procedure for ease in frequent applications. RESULTS: The images obtained by direct scanning of stomach samples showed excellent morphologic visualization of gastric lesions. The standard spots having variable areas of same density, or same areas of variable densities, showed a direct relation with signal intensity (pixels). A linear correlation was observed between measured and actual values of the known standard areas. The representative samples of indomethacin- and ethanol-induced gastric ulcers showed the total lesion areas of 4.62+/-0.74 and 169.26+/-13.23 mm(2), respectively. DISCUSSION: Direct scanning of stomach samples is a simple, cost-effective, rapid, and efficient procedure for morphologic evaluation of experimental gastric lesions. The output images of scanned stomach samples are superior to scanned photographs, and can be instantly used for quantitative assessment of mucosal injury using the image analysis program.

Animals↗
PubMed1977

Computer utilization for intravenous nutrition in surgical neonates preliminary report.

A program was developed to store important numerical clinical data such as daily weights, intravenous caloric intake, and laboratory test results on surgical neonates who required total intravenous nutrition. Preliminary experience with the data from the first 5 surgical neonates requiring intravenous nutrition indicated that this data processing is easily achieved. Data retrieval by the development of output programs provided rapid access to stored records, rapid data tabulation, and graphic print-out of parameters, such as intravenous calories per kilogram per day and weight gain, that can be placed in the patient's record.

Body Weight↗
PubMedDate not supplied

Organization and function of academic psychiatric emergency services.

Psychiatric emergency services (PES) are evolving as freestanding, parallel components of emergency departments at many tertiary care medical centers in the U.S. While PES facilities provide an increasing percentage of first-line care for patients with psychiatric crises, the services they provide and their interactions with medical emergency services have not been systematically assessed. The purpose of this study was to examine PES structure, care processes, patient characteristics and relationship with medical emergency services by surveying PES directors with a 70-item questionnaire about PES facilities in 1998. This report presents information about staffing adequacy, medical evaluation and other procedures, length of stay, and aftercare. The response rate was 91% (n=51), and most sites (>90%) were academic training sites. A large percentage (92%) of PES sites were open 24 h a day, 7 days a week, and 94% had an attending psychiatrist present at least 8 h daily. PES psychiatrists performed initial medical evaluation at 55% of sites and were often responsible for medical clearance. Pharmacologic therapy was routinely initiated for patients being admitted in 92% of facilities and for patients being released in 70% of facilities. Mean (SD) length of stay in the PES was 9.0 (11.3) hours. The PES facilities were effective at referring patients to aftercare, and 51% of PES sites provided follow-up care. However, 69% of respondents reported inadequate referral options for patients with substance abuse. The mean recidivism rate was 18%, primarily attributed to substance abuse and medication noncompliance. The results of this survey show that PES facilities are organizationally complex units in which staff routinely perform medical clearance, initiate treatment, and coordinate aftercare. Our findings highlight the importance of adequate medical training for PES psychiatrists, the need for improved aftercare programming, and better access to substance abuse treatment for discharged patients.

Academic Medical Centers↗
PubMed1999

Predictors of persistent social impairment among recovered depressed outpatients.

BACKGROUND: Though the social functioning of most depressed outpatients improves with effective treatment, a subgroup may remain impaired after recovering from depression. The purpose of this study was to identify predictors of residual social impairment among patients who recovered from depression. METHODS: These data were obtained from the Treatment of Depression Collaborative Research Program (TDCPR) public access tape. The TDCPR tested the relative efficacy of two psychotehrapies, imipramine, and placebo in major depression. Patients received follow-up assessments after completing the clinical trial. The following assessment instruments were used to assess predictor variables: Social Adjustment Scale II, Personality Assessment Form (PAF), Longitudinal Interval Follow-up Events (LIFE), and the Schedule for Affective Disorders (SADS). RESULTS: Recovered patients who were socially impaired at the end of treatment and six months later, had a higher rate of Intermittent Depression, and reported greater malfunctioning during adolescence than recovered patients whose functioning was unimpaired after treatment and at follow-up. The rates of personality disorders were not significantly different between these groups. LIMITATIONS: These analyses were performed post-hoc and the sample size was small. CONCLUSIONS: A chronic course of depression predicted persistent social maladjustment among patients who recovered from depression for 6 months.

Adolescent↗
PubMed1998

Effect of a large managed care program on emergency department use: results from the CHAMPUS reform initiative evaluation.

STUDY OBJECTIVE: To determine the effect of the CHAMPUS Reform Initiative (CRI) on emergency department use and charges, and to ascertain whether any reductions were concentrated among repeat users of the ED, those with less serious ED diagnoses, or those with selected chronic medical conditions. METHODS: Participants were approximately 1.2 million beneficiaries of the Civilian Health and Medical Program of Uniformed Services (CHAMPUS) residing within either 11 military hospital catchment areas in California and Hawaii ("demonstration areas") or 11 matched control areas in other parts of the United States. Under CRI, participants were offered a choice of the standard CHAMPUS indemnity plan, a Preferred Provider Organization-type plan, or a network-model Health Maintenance Organization plan. Beneficiaries were encouraged to use alternatives to the ED for nonemergency conditions. Visits to civilian EDs during two 12-month periods, before and after institution of CRI, were compared. RESULTS: Under CRI, the number of CHAMPUS ED visits decreased by approximately 40% relative to the control, and allowed charges fell by almost 50%. Relative reductions in ED use under CRI were seen among both frequent and infrequent users of the ED. ED case-mix severity increased modestly relative to control (+3.5% versus +.9%). ED use among patients with diabetes, hypertension, and asthma fell sharply in the demonstration areas (by 14% to 41%) but rose in control areas (by 4% to 9%). CONCLUSION: In one of the largest managed care demonstrations ever conducted, a nonintrusive use management program and improved access to outpatient care appeared to reduce ED use, allowed charges, and costs to the government. Reductions in ED use were concentrated to some extent among repeat users and patients with less severe illnesses and were effected without capitation of provider groups or strict gatekeeping requirements.

California↗
PubMed1998

The meanings of tuberculosis for Mexican migrant farmworkers in the United States.

The timely diagnosis and treatment of tuberculosis is an important public health problem in both developed and developing nations. In the United States, migrant farmworkers are estimated to be about six times more likely than other employed adults to develop tuberculosis. The purpose of this study was to investigate explanatory models of tuberculosis among Mexican migrant farmworkers working in western New York state. In-depth interviews were conducted with 26 farmworkers using an open-ended question format. All interviews were conducted in migrant camps and were audio-taped, translated and transcribed by the researcher. Data analysis was performed using Glaser and Strauss' grounded theory method of analysis which involves continuous and simultaneous data collection, coding, and analysis. Study participants included 21 males and 5 females ranging in age from 18 to 65. Respondents had worked as migrant farmworkers an average of 10 years and had an average of five years of schooling. Two-thirds of the participants had previously attended a tuberculosis education program, and four had received treatment for tuberculosis infection in the past. Farmworkers' explanations of tuberculosis etiology, severity, symptoms, prevention, treatment, and social significance are described as well as their beliefs about tuberculosis skin testing and the bacillus Calmette-Guérin (BCG) vaccine. Migrant farmworkers' explanatory models were similar in many aspects to the medical model of tuberculosis, although farmworkers had numerous misconceptions about BCG vaccination. Health care workers should be aware that Mexican migrant farmworkers may have beliefs about tuberculosis that are very compatible with participation in testing and treatment programs if such programs are made accessible to them.

Adolescent↗
PubMed2001

Outcomes of out-of-hospital cardiac arrest patients in Perth, Western Australia, 1996-1999.

STUDY OBJECTIVE: To describe the epidemiology and survival from out-of-hospital cardiac arrest. DESIGN: Longitudinal follow-up study from the time of paramedic attendance to 12 months later. SETTING: Perth, Western Australia (WA), a metropolitan capital city with an adult population of approximately one million people. METHOD: The St John Ambulance Australia (WA Ambulance Service Incorporated) cardiac arrest database was linked to the WA hospital morbidity and mortality data using probabilistic matching. INCIDENCE: Of 3730 cardiorespiratory arrests in 1996-1999, the age standardised rate of arrests of presumed cardiac origin, where resuscitation was attempted (n=1293) was 32.9 per 100000 person-years and 7.1 per 100000 person-years for bystander-witnessed VF/VT arrests. SURVIVAL: Survival to 28 days was 6.8% following all bystander-witnessed cardiac arrests; 10.6% following bystander-witnessed VF/VT arrests and 33% for paramedic-witnessed cardiac arrests. Logistic regression analysis showed an inverse association between ambulance response time interval and survival following all bystander-witnessed cardiac arrests (and VF/VT arrests). ONE YEAR SURVIVAL: 89% of bystander-witnessed cardiac arrest survivors and 92% of paramedic-witnessed cardiac arrests were still alive at 1 year post-arrest. CONCLUSION: The trends in occurrence and survival following out-of-hospital cardiac arrest in Perth, WA, are similar to those found elsewhere. There is an opportunity to strengthen the chain of survival by reducing the response time interval and increasing the use of bystander cardiopulmonary resuscitation (CPR). First-responder programs and public access defibrillation will need to be considered in the light of local demographics, location and the epidemiologic features of out-of-hospital cardiac arrest.

Adult↗
PubMedDate not supplied

Substance abuse treatment for pregnant women: a window of opportunity?

The use of substance abuse treatment services by pregnant and nonpregnant women was compared to explore the effects of pregnancy on treatment utilization and outcomes. Treatment service records for 227 pregnant drug- and alcohol-dependent women and a matched comparison group of 277 nonpregnant women were retrieved from the Massachusetts Bureau of Substance Abuse Services Management Information System. Treatment services received by the two groups of women during a 6-month period following an index detoxification were tabulated and compared. Treatment services for pregnant women differed quantitatively and qualitatively from the services received by nonpregnant women over the 6-month time period. After controlling for background characteristics and substance abuse history, pregnant women were 1.7 times more likely to be readmitted to detoxification, 2.8 times more likely to enter residential facilities, and 5.4 times more likely to enter methadone programs. For both groups, the use of outpatient and/or residential treatment services following discharge from detoxification significantly reduced the risk of subsequent detoxification admissions. The increased likelihood of admission to detoxification, residential, and methadone services suggests that treatment programs have improved access to care for pregnant women. Multiple detoxification admissions suggest, however, that some pregnant women have difficulty entering stable recovery. Given the brevity of the gestational period and the detrimental effects of drug and alcohol use on fetal outcomes, the use of continuing treatment services for pregnant women is strongly recommended.

Adolescent↗
PubMed2006

[Subtotal hysterectomy: evolving concepts with implications for practice].

INTRODUCTION: The advantages and drawbacks of total and sub-total hysterectomy remain a topic of debate. Our study reviews the literature concerning recent comparative and prospective studies regarding the options of total and subtotal hysterectomy. RESULTS: Subtotal hysterectomy may be useful in preventing severe complications when total hysterectomy is technically difficult. Furthermore, conservation of the uterine cervix may decrease vaginal erosion in genital prolapse repair when synthetic meshes are used. The type of technique does not appear to determine the persistence or development of problems related to sexual activity (frequency of intercourse, sexual desire, and achievement of orgasm). There are no apparent advantages to subtotal hysterectomy compared with total hysterectomy with respect to bowel or bladder function. Some women (5-20%) who had the subtotal procedure continued to have genital bleeding, although this can be avoided with endocervical electro-coagulation or resection. Cervical stump prolapse is uncommon (1.5-2%), 12 months after subtotal hysterectomy. The risk of carcinoma of the cervical stump is low, and treatment results are similar in both patients with carcinoma of the cervical stump and in patients with carcinoma of the intact uterus. CONCLUSION: When subtotal hysterectomy is necessary, it can be performed with a low rate of long term complications. Furthermore, for women undergoing hysterectomy for benign disease, it should be reasonable to discuss advantages and drawbacks of both procedures and offer a choice. Nevertheless, sub-total hysterectomy should be avoided in populations with restricted access to screening programs for cancer of the uterine cervix.

Female↗
PubMed1991

Treatment predictors of tenure in methadone maintenance.

Tenure in methadone maintenance treatment was analyzed in terms of treatment process factors using a survival curve regression analysis. The treatment process framework included client variables at entry, program characteristics, treatment events, and client attitudes and satisfaction. The sample consisted of 606 methadone maintenance clients from 21 different clinics. Significant predictors included professional classifications of the diagnosing and treatment-planning staff members, measures of early treatment services, client attitudes and satisfaction, methadone dosage level, and frequency of urine monitoring. The results showed higher tenure rates when specialized professionals diagnosed problems and defined treatment plans, when service needs were addressed, when client attitudes and satisfaction were high, and when methadone dose was higher. Lower tenure rates were found among blacks and clients with lower sociodemographic status. Lower tenure also occurred among those who perceived the program as less accessible or less structured in its procedures.

Black or African American↗
PubMed2006

Factors associated with acute health care use in a national adult asthma management program.

BACKGROUND: The use of acute health care resources for asthma is considerable. Disease severity is an established risk factor, but ethnicity and health care factors are less well studied. OBJECTIVE: To investigate the independent associations of ethnicity and health care factors with acute resource use for asthma. METHODS: Longitudinal data from a national adult asthma management program providing universal access to care were analyzed. Outcome measures were unscheduled physician visits with urgent nebulization, emergency department (ED) visits, and hospitalizations. RESULTS: In multivariate analyses, markers of disease severity were found to be significantly associated with all acute resource use. After controlling for disease severity, ethnicity was associated with increased risk of all acute resource use; Indian (vs Chinese) ethnicity was associated with increased risk of unscheduled physician visits (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.03-1.70), ED visits (HR, 1.61; 95% CI, 1.12-2.32), and hospitalizations (HR, 1.49; 95% CI, 1.03-2.16). Malay ethnicity was associated with unscheduled physician visits (HR, 1.30; 95% CI, 1.01-1.68) and ED visits (HR, 1.55; 95% CI, 1.09-2.19). Default of follow-up appointments was associated with unscheduled physician visits (HR, 1.47; 95% CI, 1.08-2.00), ED visits (HR, 2.35; 95% CI, 1.59-3.45), and hospitalizations (HR, 1.74; 95% CI, 1.09-2.76). Poor inhaler technique was associated with ED visits (HR, 1.86; 95% CI, 1.05-3.30) and smoking with unscheduled physician visits (HR, 1.38; 95% CI, 1.09-1.76). CONCLUSIONS: In addition to markers of asthma severity, ethnicity, smoking, discontinuity of care, and self-care behavior are risk factors for acute resource utilization and represent target groups and elements of asthma intervention for improving asthma outcomes.

Adult↗
PubMed2006

Abortion and maternal mortality in the developing world.

Unsafe abortion is an important public health problem, accounting for 13% of maternal mortality in developing countries. Of an estimated annual 70,000 deaths from unsafe abortion worldwide, over 99% occur in the developing countries of sub-Saharan Africa, Central and Southeast Asia, and Latin America and the Caribbean. Factors associated with increased maternal mortality from unsafe abortion in developing countries include inadequate delivery systems for contraception needed to prevent unwanted pregnancies, restrictive abortion laws, pervading negative cultural and religious attitudes towards induced abortion, and poor health infrastructures for the management of abortion complications. The application of a public health approach based on primary, secondary, and tertiary prevention can reduce morbidity and mortality associated with unsafe abortion in developing countries. Primary prevention includes the promotion of increased use of contraception by women (and by men) at risk for unwanted pregnancy; secondary prevention involves the liberalization of abortion laws and the development of programs to increase access to safe abortion care in developing countries. In contrast, tertiary prevention includes the integration and institutionalization of post-abortion care for incomplete abortion and the early and appropriate treatment of more severe complications of abortion. Efforts to address these problems will contribute both to reducing maternal mortality associated with induced abortion and to achieving the Millennium Development Goals in developing countries.

Abortion, Induced↗
PubMed1999

An empirical test of language-relevant interventions for dementia.

The focus of this report is the treatment of persons with dementia who are of a non-English-speaking background (NESB). Noisemaking is one behavioral manifestation associated with severe dementia. It can have devastating effects on persons with dementia by limiting their access to activity programs and social interaction, and is also very distressing for professionals and family carers. It can be especially difficult for carers when they do not speak the first (non-English) language of the person with the noisemaking problem, when the person has lost his or her ability to speak English as the dementia progresses. Behavioral interventions have been found to be successful in decreasing the occurrence of noisemaking in some people with severe dementia. This article reports on a study of an elderly Italian woman with dementia. The study used a randomized, alternating-treatments design in order to determine whether an Italian-language intervention would be more effective in reducing her noisemaking than the same intervention given in English. The main result of the study was that the Italian intervention was found to be significantly more effective in reducing noisemaking than the English intervention. Therefore, this exploratory study provides empirical evidence for the increased effectiveness of an intervention program in the patient's original language. The study also demonstrates the need for individualized intervention programs, particularly for NESB patients living in predominantly English-speaking institutions.

Aged↗
PubMed2002

Employment histories of homeless persons with mental illness.

This study examined the work histories of 7,228 homeless persons with mental illness who were enrolled into the multi-site Access to Community Care and Effective Services and Supports (ACCESS) research demonstration program. Multiple logistic regression analyses suggest that use of vocational services is significantly associated with increased likelihood of paid employment. The role of vocational rehabilitation services in removing persons from homelessness and improving their quality of life is discussed.

Adult↗
PubMed1995

Is weight gain after smoking cessation inevitable?

Weight gain after smoking cessation was studied in a naturalistic setting where (1) all smokers quit and (b) risk factors for postcessation weight gain were modified. Participants were 332 military recruits (227 men, 105 women), 86 of whom were smokers who quit during 6 weeks of basic training. Results showed no significant weight changes for smokers who quit. Pretest smoking rates and feat of weight gain were unrelated to changes in weight. Results suggest that an intensive program that limits access to alcohol and foods that are high in fat and that increases physical activity can attenuate weight gain after smoking cessation.

Adolescent↗
PubMed1992

Funding Head Start: what are the issues?

Despite its current popularity in Congress, budgetary constraints dictate that future appropriations for Head Start will inevitably fall short of the amount needed to provide increased access to the program and sufficient improvement of its services. Issues are examined, competing policy options are analyzed, and a hierarchy of needs for future funding is proposed.

Budgets↗
PubMed2003

Vascular access and patient outcomes in hemodialysis: questions answered in recent literature.

Hemodialysis is not possible without access to the vascular system to provide an adequate and reliable source of blood flow through the hemodialyzer. Since maintenance hemodialysis therapy became a reality in the latter half of the twentieth century, no vascular access has exceeded the success and reliability of arteriovenous fistulae (AVF). They have the lowest infection and thrombosis rates, have the longest patency rates, and are associated with the best morbidity and mortality outcomes of any access modality. In the United States, the majority of patients starting hemodialysis do not have a primary AVF, which may explain why vascular access complications represent almost 20% of the total spending for hemodialysis. In addition, as much as 50% of hospitalization costs for end-stage renal disease are related to access issues. Every effort must be directed in the U.S. as well as elsewhere to promote the use of AVF whenever possible. In some European countries, more than 90% of patients have AVF as their hemodialysis access when nephrologists perform placement of vascular access. Already, some programs in the U.S. have recognized the need for trained nephrologists to provide these services. U.S. interventional nephrologists should be given the opportunity to learn AVF placement procedures to emulate their European counterparts, and thus improve U.S. dialysis outcomes.

Arteriovenous Shunt, Surgical↗