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Designated case managers as facilitators of medical and psychosocial service delivery in addiction treatment programs.

This study examines whether having designated case management staff facilitates delivery of comprehensive medical and psychosocial services in substance abuse treatment programs. A multilevel, prospective cohort study of 2829 clients admitted to selected substance abuse treatment programs was used to study clients from long-term residential, outpatient, and methadone treatment modalities. Program directors reported whether the program had staff designated as case managers. After treatment discharge, clients reported their receipt of 9 supplemental services during the treatment episode. In multivariate models controlling for multiple program-level and client-level factors, program-level availability of designated case managers increased client-level receipt of only 2 of 9 services, and exerted no effect on service comprehensiveness, compared to programs that did not have designated case managers. These findings do not support the common practice of designating case management staff as a means to facilitate comprehensive services delivery in addiction treatment programs.

Adolescent↗

Multilevel models: applications to health data.

This paper presents an introductory account of multilevel models, highlighting the potential benefits that may be gained by the use of these methods. It draws on recent applications in health services research that have appeared in the literature. Methodological advances in these statistical techniques have taken place in the field of education, where empirical studies have mainly been concerned with comparing pupil achievement across different schools by exploring the relationship between individual and institutional factors. Although recent widespread availability of suitable software packages has enabled other disciplines to adopt these methods, to date they have received little attention in the health services research literature (the investigation of effects of geographical areas on health being a possible exception) despite their obvious application in many areas of current interest. Key areas that could benefit greatly from these techniques include the exploration of variations in clinical practice, comparisons of institutional performance and resource allocation.

Health Behavior↗

Assessing the performance of community systems for children.

OBJECTIVE: To present a framework for measuring the quality of community systems for children, based on key attributes of systems performance for children's services. We present a research agenda for refining the model, evaluating indicators across the performance domains identified, developing normative standards for performance, and assessing the empirical basis for performance criteria. PRINCIPAL FINDINGS: Systems performance can be measured. A systems approach to evaluating community systems for children needs to incorporate the multilevel service delivery networks, programs, and systems of care for children. A model of community systems performance for children includes key dimensions of structure, financing, and accountability. Attributes within these dimensions serve as indicators that communities can use to evaluate systems quality. Performance standards can be based on the evidence from field demonstrations as well as from normative assessments. RECOMMENDATIONS: The model of community systems performance should be refined and developed using empirical findings of analyses of children's systems. A set of indicators that capture vital aspects of performance and that are relevant, scientifically valid, and feasible should be developed and tested in field studies. Once indicators are evaluated for use in performance monitoring, communities will be able to implement performance monitoring.

Child↗

Determinants of androgen deprivation therapy use for prostate cancer: role of the urologist.

BACKGROUND: The use of androgen deprivation therapy for prostate cancer has been increasing, even in settings for which there is weak or no evidence of efficacy. This pattern suggests that factors other than the typical patient and tumor characteristics may be driving its use. We assessed the importance of the physician as a determinant of the use of androgen deprivation therapy in prostate cancer in a population-based, retrospective cohort study using the Surveillance, Epidemiology and End-Results-Medicare linked database. METHODS: Participants included 61 717 men with incident prostate cancer diagnosed from January 1, 1992, through December 31, 1999, and 1802 urologists providing care to them within 1 year of cancer diagnosis. Multilevel analyses were used to estimate and partition the variance in use of androgen deprivation therapy within 6 months of diagnosis between patient or tumor characteristics and urologist to examine the relative contribution of each component to androgen deprivation therapy. RESULTS: The percentage of the total variance in the use of androgen deprivation therapy attributable to the urologist was consistently higher than that attributable to tumor or patient characteristics. This pattern was most pronounced for patients diagnosed from January 1, 1997, through December 31, 1999, in which 22.56% of the total variance in use of androgen deprivation therapy was attributable to the urologist, 9.71% to tumor characteristics (stage or grade), and 4.29% to patient characteristics (age, ethnicity, socio-economic status, comorbidity, geographic region, or year of diagnosis). CONCLUSIONS: Which urologist a patient sees may be more important in determining whether they will receive androgen deprivation therapy than tumor or patient characteristics.

Aged↗

Molecular physiology of the regulation of hepatic gluconeogenesis and glycolysis.

Understanding the regulation of hepatic glucose metabolism had its foundation in the elucidation of several pathways, but recent advances have come from the application of molecular genetics. Five years ago little was known about the primary structure of the key regulatory enzymes. Since then, the primary sequence of liver GK, 6-PF-1-K, Fru-1,6-P2ase, PK, PEPCK, and 6-PF-2-K/Fru-2,6-P2ase have been derived from cDNA sequences and/or determined by direct protein sequencing. This has provided new insights into the molecular mechanisms of catalysis and the regulation of these enzymes by covalent modification. Isolation of the cDNAs for these enzymes also has allowed for the quantitation of specific mRNAs and permitted analysis of hormonal control of specific gene expression. The genes for these enzymes have been isolated and sequenced, and their promoter regions are being identified and characterized. Hormone response elements have been delineated in several of the promoters. The promoter regions for 6-PF-2-K/Fru-2,6-P2ase and Fru-1,6-P2ase have also been identified, and future research will focus on the elucidation of the mechanisms whereby hormones regulate the expression of these genes. A number of generalizations can be made about the regulation of gene expression of glycolytic/gluconeogenic enzymes. First, there is coordinate hormonal regulation of gene expression and these effects are consonant with their physiologic actions. Insulin induces the mRNAs that encode glycolytic enzymes and represses the mRNAs that encode gluconeogenic enzymes; cAMP has opposite effects. Both can increase or decrease transcription. Whereas insulin and cAMP affect all of these mRNAs, glucocorticoids appear to have a more restricted action. Second, transcriptional and posttranscriptional regulatory mechanisms are involved. The synthesis of all of the mRNAs discussed is regulated by hormones. Relatively little is known about how mRNA stability is regulated in general, but it is clear that PEPCK mRNA is stabilized by agents that increase the rate of transcription of the gene. Under appropriate metabolic signals this dual control of mRNA synthesis and stability provides for a long-term increase in PEPCK mRNA and protein. Studies with PK mRNA are less direct, but suggest a similar dual mechanism. It will be interesting to see whether multilevel regulation is restricted to these two mRNAs, both of which are involved in the same substrate cycle, or whether the stability of other mRNAs involved in hepatic glucose metabolism is also affected. Third, glucose appears to be important in the regulation of these hepatic genes.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom.

OBJECTIVE: To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences. DESIGN AND SETTING: Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001. PATIENTS: 118,199 adult admissions to ICUs. MEASUREMENTS AND RESULTS: The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions. CONCLUSIONS: Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.

Adolescent↗

Physical activity, exercise coping, and depression in a 10-year cohort study of depressed patients.

BACKGROUND: Epidemiological research examining the relationship between physical activity and depression has been conducted almost exclusively with community samples. We examined associations between physical activity, exercise coping, and depression in a sample of initially depressed patients, using four waves of data spanning 10 years. METHODS: A cohort (n=424) of depressed adults completed measures of physical activity, exercise coping, depression, and other demographic and psychosocial constructs at baseline, 1-year, 4-years, and 10-years, with a 90% wave-to-wave retention rate. Multilevel modeling was used to analyze individual depression trajectories. RESULTS: More physical activity was associated with less concurrent depression, even after controlling for gender, age, medical problems, and negative life events. Physical activity counteracted the effects of medical conditions and negative life events on depression. However, physical activity was not associated with subsequent depression. The findings for exercise coping were comparable. LIMITATIONS: Measures of physical activity and exercise coping encompassed a limited set of activities and did not include information about duration or intensity. CONCLUSION: Our results suggest that more physical activity is associated with reduced concurrent depression. In addition, it appears that physical activity may be especially helpful in the context of medical problems and major life stressors. Clinically, encouraging depressed patients to engage in physical activity is likely to have potential benefits with few obvious risks.

Adaptation, Psychological↗

Does work really cause distress? The contribution of occupational structure and work organization to the experience of psychological distress.

This research examines the specific contribution of occupation and work organization conditions on psychological distress, based on a representative sample of 9501 workers in 419 occupations in Quebec, Canada. Multilevel regression models show that occupational structure accounts for 0.8% of variation in psychological distress. Among the constraints and resources related to work organization condition, physical and psychological demands, irregular schedules, and workplace harassment emerge as important determinants of psychological distress. The effects of work organization conditions do not vary across occupations. Family situation, support available from social networks outside work, and personal characteristics of individuals are also associated with psychological distress, but these factors do not moderate the effects of work organization conditions. Overall, the findings support the hypothesis that occupation and, to an even greater extent, "pathogenic" work organization conditions contribute independently to the experience of psychological distress. They also support the theoretical model conceptualizing psychological distress as the product of stress caused by constraints and resources brought to bear simultaneously by the agent's personality, structures of daily life, and macrosocial structures.

Adolescent↗

Age-period-cohort effects on inequalities in psychological distress, 1981-2000.

BACKGROUND: In the closing decades of the twentieth century, changes in population sociodemographics took place that might be thought to have an adverse influence on the nation's psychological distress. Here, we examine the stability of social and gender inequalities in psychological distress throughout the 1980s and 1990s. METHODS: The study uses data from the 1958 National Child Development Study and the 1970 British Cohort Study collected when the cohort members were aged between 23 and 42. Multilevel logistic regression models were used to examine the effects of social class, gender, age, period and cohort on psychological distress as measured by the Malaise Inventory. RESULTS: We identify clear social inequalities in psychological distress during 1981-2000 that reduced in magnitude over this period. Non-linear age effects were observed: psychological distress improves in early adulthood but declines again on approaching mid-life. The 1970 cohort had poorer psychological distress than the 1958 cohort. Although women had higher rates of psychological distress than men, gender differences reduced in magnitude. Declining rates of women's psychological distress over time have not been matched in men. A reduction in social inequalities over time was also observed. Improvements in the psychological health of those in manual occupations were not equalled among those in non-manual occupations. CONCLUSIONS: Both social and gender inequalities have narrowed in the last two decades of the twentieth century.

Adult↗

Vertical facial growth and statural growth in girls: a longitudinal comparison.

Individual and average growth patterns of the facial dimensions Nasion-Gnathion and Sella-Gonion, as related to statural growth were studied. The sample consisted of 134 girls aged 7-14 years. Data were analysed using a multivariate extension of the multilevel model for longitudinal data. The results confirmed that the mean growth curves of Nasion-Gnathion, Sella-Gonion and body height parallel each other to a large extent. At an individual level it appeared that the pubertal growth spurt of body height and the growth spurts of both facial dimensions are coincident. The major results of the present study pertain to the dynamic (age-dependent) relationship between statural growth and the growth of the face. It appears that there exists a stronger relationship between the growth velocities of standing height, Sella-Gonion and Nasion-Gnathion than between the actual lengths of the three variables themselves. The strongest relation was found between the growth velocity of body height and that of Sella-Gonion. These findings may be a contribution for diagnosis and treatment planning of individual cases.

Adolescent↗

Household and neighbourhood risks for injury to 5-14 year old children.

Injuries in childhood are strongly related to poverty at the household level and to living in a deprived neighbourhood, but it is not clear whether these effects are independent. In this prospective population study, all injuries to 5-14 year old children living in the city of Norwich, UK, and presented at the hospital Accident and Emergency Department over a 13 month period were recorded (N=3526). Information on the population of resident children and household composition was assembled from the health authority population register. Neighbourhood information was extracted from the census and local surveys. Unadjusted risks were calculated for individual and neighbourhood factors, followed by multilevel modelling in which predictors were included at three levels: individual, enumeration district and social area (neighbourhood). The overall injury rate was 16.44 per 100 children per year. Injury rates between neighbourhoods varied two-fold and were highest in more deprived areas. In the final multilevel model injury risk was related to gender (boys vs. girls OR=1.35), age of child (OR=1.07 per year), number of adults in the household (OR=0.91 per adult), and age gap between child and eldest female (15-24 years vs. 25-34 years, OR=1.15). Injury rates were also related to social area deprivation, although variations in injury rates between neighbourhoods were not wholly explained by deprivation. The adjusted odds ratio between the most and least deprived social areas was 1.35. Excluding less serious injuries did not substantially change the results. The risks were very similar to those found in a previous study of pre-school children, with the same neighbourhoods identified as high and low risk as before. This evidence that neighbourhood factors independently influence injury risk over and above individual and household factors supports the use of area-based policies to reduce injuries in children.

Child↗

Pessimism and optimism as early warning signs for compromised health for caregivers of patients with Parkinson's disease.

BACKGROUND: Although pessimism and optimism are associated with health-related outcomes, the long-term effects of pessimism and optimism in the caregiving process are understudied, and little is known about their role in health changes over time. OBJECTIVE: To determine whether pessimism and optimism can be used as early warning signs for negative changes in caregiver depressive symptoms and physical health over a 10-year period. METHODS: Multilevel modeling was used to examine longitudinal data from 311 spouse caregivers of individuals with Parkinson's disease, with data points at baseline, Year 2, and Year 10. Measures included the Life Orientation Test, the Center for Epidemiological Studies-Depression Scale, and the SF-36 Health Survey physical functioning scale. RESULTS: Caregiver pessimism early in the caregiver role was found to be a warning sign for poor current and future caregiver health. High baseline pessimism signaled high levels of baseline depressive symptoms and poor physical health, as well as a faster decline in health over the 10-year study. Optimism played a role in predicting baseline depressive symptoms, although the magnitude of its beneficial contribution was not as great as the deleterious effects of pessimism. CONCLUSIONS: Nurses and clinicians have a unique opportunity to detect and intervene with caregivers who show high levels of pessimism early in the caregiving trajectory.

Adult↗

Electrostatic microactuators for precise positioning of neural microelectrodes.

Microelectrode arrays used for monitoring single and multineuronal action potentials often fail to record from the same population of neurons over a period of time likely due to micromotion of neurons away from the microelectrode, gliosis around the recording site and also brain movement due to behavior. We report here novel electrostatic microactuated microelectrodes that will enable precise repositioning of the microelectrodes within the brain tissue. Electrostatic comb-drive microactuators and associated microelectrodes are fabricated using the SUMMiT V (Sandia's Ultraplanar Multilevel MEMS Technology) process, a five-layer polysilicon micromachining technology of the Sandia National labs, NM. The microfabricated microactuators enable precise bidirectional positioning of the microelectrodes in the brain with accuracy in the order of 1 microm. The microactuators allow for a linear translation of the microelectrodes of up to 5 mm in either direction making it suitable for positioning microelectrodes in deep structures of a rodent brain. The overall translation was reduced to approximately 2 mm after insulation of the microelectrodes with epoxy for monitoring multiunit activity. The microactuators are capable of driving the microelectrodes in the brain tissue with forces in the order of several micro-Newtons. Single unit recordings were obtained from the somatosensory cortex of adult rats in acute experiments demonstrating the feasibility of this technology. Further optimization of the insulation, packaging and interconnect issues will be necessary before this technology can be validated in long-term experiments.

Action Potentials↗

Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures--the public health disparities geocoding project.

Use of multilevel frameworks and area-based socioeconomic measures (ABSMs) for public health monitoring can potentially overcome the absence of socioeconomic data in most US public health surveillance systems. To assess whether ABSMs can meaningfully be used for diverse race/ethnicity-gender groups, we geocoded and linked public health surveillance data from Massachusetts and Rhode Island to 1990 block group, tract, and zip code ABSMs. Outcomes comprised death, birth, cancer incidence, tuberculosis, sexually transmitted infections, childhood lead poisoning, and nonfatal weapons-related injuries. Among White, Black, and Hispanic women and men, measures of economic deprivation (e.g., percentage below poverty) were most sensitive to expected socioeconomic gradients in health, with the most consistent results and maximal geocoding linkage evident for tract-level analyses.

Adolescent↗

Craniofacial growth in growth hormone-deficient rats after growth hormone supplementation.

INTRODUCTION: Growth hormone (GH) supplementation is an established therapy to increase stature in GH-deficient or short-for-age children, but comparatively little is known of its effects on the craniofacial skeleton. METHODS: Using a mutant strain of Lewis rats (dw/dw) in which GH levels were 6% to 10% of normal, but other trophic hormones were unaffected, we investigated the differential susceptibility of craniofacial measures to GH supplementation, characterized their potential for partial or complete catch-up growth, and compared their growth changes with those in long bones. At 24 days of age and for 3 subsequent weeks, radiographs of the lateral head, upper limb, and lower limb were obtained from 3 groups of growing rats (n = 8-9 in each group): dwarf (experimental) with GH injection, dwarf (sham) with vehicle injection, and wild type (control) with vehicle injection. The x-ray images were scanned, standardized points digitized, and linear distances measured. Absolute growth curves were generated for each group by using multilevel modeling procedures and iterative generalized least-squares curve fitting. RESULTS: For every measure, growth differences were evident between the experimental and the sham groups, but the treatment effect varied inversely with relative maturity of the measure. Although all craniofacial measures showed some catch-up growth, only 31% of craniofacial measures had complete catch-up compared with all limb measures. The percentage of catch-up varied inversely with relative maturity of the measure. Our results suggest that the effects of GH supplementation vary considerably, so that measures with the lowest relative maturity (greatest baseline potential) show the greatest treatment effect and catch-up, whereas more mature measures show less growth response to GH replacement. CONCLUSIONS: These results suggest that, depending on the timing of GH supplementation, there is potential for change in proportions or shape of the craniofacial complex.

Age Factors↗

[A longitudinal study on growth model and velocity of term small for gestation age].

To probe into the vegetal pattern and find out the key period of promoting normal growth of term small for gestational age (TSGA), a longitudinal study on growth model and velocity of TSGA was conducted from Jan 1993 to June 1997. The body weight and length of 150 children of TSGA (57 boys, 93 girls) and 152 children as controls (58 boys, 94 girls) were measured from the 1st month to 36th month. The growth model was analysed by multilevel models. The result showed that there was a difference between the growth models of TSGA and controls. During 8 and a half months (center month), the weight, length of controls were 1.19 kg, 3.46 cm greater than those of TSGA; the weight, length of boys were 0.34 kg, 1.08 cm more than those of girls respectively. The growth velocity of TSGA was similar to that of controls. The maximal growth velocity was observed during the first 6 monthes after birth. The order of growth velocity from high to low was 1 mo. > 2 mo. > 3 mo. in length and weight, showing that children of TSGA have their own growth model. Their growth velocity should be monitored attentively. If low velocity appears one should search for the cause and adopt apropriate measures to ensure their growth in accordance with their "own track".

Body Height↗

Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods.

BACKGROUND: As part of the Worcester Heart Attack Study, a community-wide study examining changes over time in the incidence and long-term case-fatality rates of greater Worcester, Mass, residents hospitalized with confirmed acute myocardial infarction (AMI), we investigated the hypothesis that census tract-level socioeconomic position is an important predictor of survival after hospital discharge for AMI, after adjusting for demographic and clinical characteristics. METHODS AND RESULTS: Data were available for 3423 confirmed cases of AMI among metropolitan Worcester residents during the 4 study years of 1995, 1997, 1999, and 2001 who were followed up through the end of 2002. The mean age among patients was 69 years, and 58% were men. Using a multilevel Cox proportional hazards regression model, we estimated a 30% higher death rate after AMI for patients living in census tracts with the most residents living below the poverty line compared with patients living in the wealthiest census tracts (relative risk=1.30; 95% CI, 1.08 to 1.56). Similarly, patients living in census tracts with the highest proportion of residents with less than a high school education experienced a 47% higher death rate than patients living in census tracts with the lowest proportion of residents with less than a high school education (relative risk=1.47; 95% CI, 1.15 to 1.88). CONCLUSIONS: Within a medium-sized urban area, there are important variations in survival after hospital discharge for AMI that are associated with socioeconomic position. These associations persist after adjustment for demographic and clinical characteristics. Reasons for these differences warrant further investigation.

Aged↗

A contextual model of adolescent alcohol use across the rural-urban continuum.

In the research presented here, we develop and test with respondents from a broad range of contexts a multilevel social control model of adolescent substance use, integrating macro- and microsociological and criminological perspectives. Specifically, this research examines the individual-level social control processes or mechanisms thought to lead to alcohol use embedded in school contexts in different community settings along the rural-urban continuum. In this way we determine 1) the main effects of individual- and contextual school-level variables and 2) the conditioning or moderating influences of school climate on individual alcohol use and on individual-level processes leading to alcohol use. Furthermore, given that our sample contains students from a broad range of settings along the rural-urban continuum, our findings address the appropriateness of conceptualizing rural and urban drug use and their respective etiologies as dichotomous. In this respect our findings suggest that heterogeneity in drug use exists within rural school settings as well as within urban school settings, and that examining rural drug use as separate from urban drug use is not justified.

Adolescent↗