Does stress influence early pregnancy loss?

PURPOSE: The purpose of this study is to examine the relationship between stress, cortisol level and the risk for spontaneous abortion and determine the influence of stress on health-related behaviors. METHODS: Three hundred and twenty-six pregnant women presenting to the emergency department at the Hospital of the University of Pennsylvania from March 1999 through March 2000 were recruited and followed through 22 weeks gestation. Cases were women who experienced a spontaneous abortion and controls were women who maintained their pregnancy. Stress was measured by the Perceived Stress Scale (PSS), the Prenatal Social Environment Inventory (PSEI) and the Index of Spousal Abuse (ISA) prior to confirmation of spontaneous abortion. Blood samples were collected to measure cortisol and sex hormone levels. Urine samples were collected to assess cotinine, cocaine and marijuana use. RESULTS: No relationship was found between psychosocial stress, as determined by the three stress scales or cortisol level, and the risk for spontaneous abortion. Women with high stress, as measured by the PSEI, were more likely to use cigarettes and marijuana during pregnancy. High psychosocial stress during early pregnancy was not related to spontaneous abortion but high stress was associated with substance use during pregnancy. CONCLUSION: The influence of psychosocial stress on the risk of spontaneous abortion is unclear.     

Does disorder get “into the head” and “under the skin”? Layered contexts and bi-directional associations

This paper utilizes a layered context approach to examine how neighborhood and household conditions are associated with the objective and subjective well-being of older adults. Using two waves of data from the National Social Life, Health, and Aging Project (n=2261), we assess subjective mental health through self-reported measures of perceived stress and distress and objective physical health through C-reactive protein (CRP). Environmental disorder was measured by independent, trained interviewers. Cross-sectional results indicate that household disorder is positively associated with perceived stress and distress, overwhelming the association between neighborhood disorder and mental health outcomes. Yet longitudinal findings point to a reverse process, whereby highly stressed women experience deterioration in their home environment across the two waves. Few significant findings surfaced for CRP. Taken together, our findings illustrate the complex interplay between health and proximal environments and underscore how feedback cycles operate between “health” and “place” across multiple outcomes.     

Does tobacco marketing undermine the influence of recommended parenting in discouraging adolescents from smoking?

OBJECTIVE: The tobacco industry contends that parenting practices, not marketing practices, are critical to youth smoking. Our objective was to examine whether tobacco-industry marketing practices undermine the protective effect of recommended authoritative parenting against adolescent smoking. DESIGN AND SETTING: Receptivity to tobacco advertising and promotions was assessed in 1996 from a representative sample of California adolescent never-smokers aged 12 to 14 years. A follow-up survey of 1641 of these adolescents was conducted in 1999 that included measures of the key components of authoritative parenting: parental responsiveness, monitoring, and limit setting. MAIN OUTCOME MEASURE: Smoking initiation in adolescents. RESULTS: Adolescents in families with more-authoritative parents were half as likely to smoke by follow-up as adolescents in families with less-authoritative parents (20% vs 41%, p <0.0001). In families with more-authoritative parents, adolescents who were highly receptive to tobacco-industry advertising and promotions were significantly more likely to smoke (odds ratio=3.52, 95% confidence interval =1.10-11.23), compared to those who were minimally receptive. This effect was not significant in adolescents in families with less-authoritative parents. The overall attributable risk (adjusted for exposure to peer smokers) of smoking from tobacco-industry advertising and promotions was 25%. However, an estimated 40% of adolescent smoking in families with more-authoritative parents was attributable to tobacco-industry advertising and promotions; this was five times the attributable risk seen in families with less-authoritative parents (8%). CONCLUSION: The promotion of smoking by the tobacco industry appears to undermine the capability of authoritative parenting to prevent adolescents from starting to smoke.     

Does exposure to medically underserved areas during training influence eventual choice of practice location?

INTRODUCTION: There are an increasing number of communities within the United States that have limited or no access to primary healthcare. In recognition, many medical schools now provide opportunities and activities that offer exposure to these demographic areas in order to increase the presence of and community access to medical care and to promote these locations as practice site choices for graduating students. Evaluation of these enhancements has led to doubts whether this exposure timing is optimal in promoting practice in these settings. The purpose of this study is to identify whether early exposure(s) to medically underserved settings prior to medical school is associated with eventual choice of practice location. METHODS: Utilising a cross-sectional design, 450 US Family Medicine residency programmes were surveyed. From these, 775 participants responded to a standardised self-administered questionnaire on indicators associated with medically underserved area (MUA) exposure. RESULTS: Early MUA exposures combined with medical training experiences in underserved settings have a positive effect on later practice site choice. Identification of these attributes may be useful in considering determinants that impact eventual choice of practice location.     

Does self-selection influence the relationship between park availability and physical activity?

Objective.

Increased proximity to parkland is associated with physical activity (PA). This study explored the extent to which self-selection - the idea that active persons simply seek out neighborhoods more endowed with active resources - influences the relationship between park availability and PA.

Method.

In August 2007, measures of parkland availability within 1 km, importance placed on living near parks, and park-based PA participation were assessed for 585 adults in Waterloo, Ontario.

Results.

Logistic regression revealed that (i) participants who placed greater importance on neighborhood open space were not more likely to live near more parkland; (ii) both park importance and park space availability were associated with increased, and relatively equal, odds of engaging in at least some park-based PA; and (iii) participants who placed a low importance on living near parks but had a higher amount of park space nearby were significantly more likely to engage in park-based PA than participants who also placed a low importance on parks but had less nearby park space.

Conclusion.

The issue of self-selection does not solely account for the relationship frequently observed between park space availability and PA. Future prospective and intervention studies are needed to draw more definitive conclusions about causality.     

Does socio-demographic status influence the effect of pollens and molds on hospitalization for asthma? Results from a time-series study in 10 Canadian cities

PURPOSE: Social status influences asthma morbidity but the mechanisms are not well understood. To determine if sociodemographics influence the susceptibility to ambient aeroallergens, we determined the association between daily hospitalizations for asthma and daily concentrations of ambient pollens and molds in 10 large Canadian cities. METHODS: Daily time-series analyses were performed and results were adjusted for day of the week, temperature, barometric pressure, relative humidity, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide. Results were then stratified by age, gender, and neighborhood family education and income. RESULTS: There appeared to be age and gender interactions in the relation between aeroallergens and asthma. An increase in basidiomycetes equivalent to its mean value, about 300/m3, increased asthma admissions for younger males (under 13 years of age) by 9.3% (95% CI, 4.8%, 13.8%) vs. 4.2% (95% CI, - 0.1%, 8.5%) for older males. The reverse was true among females with increased effect in the older age group: 2.3% (95% CI, 1.2%, 5.8%) in those under 13 years vs. 7.1% (95% CI, 4.1%, 10.1%) for older females. Associations were seen between aeroallergens and asthma hospitalization in the lowest but not the highest education group. CONCLUSIONS: Our results suggest that younger males and those within less educated families may be more vulnerable to aeroallergens as reflected by hospitalization for asthma.     

Does the patient's sex influence cardiovascular outcome after acute myocardial infarction?

OBJECTIVES: To determine whether outcome differences based on the patient's sex occur after myocardial infarction (MI) at a large private hospital. STUDY DESIGN: We conducted a large cohort study. POPULATION: Inclusion required hospital admission between January 1, 1998, and June 30, 1999, and a diagnosis of acute MI or subendocardial infarction. The number of patients included in the study was 1669. Data were collected at discharge on age, sex, race, health insurance, hypercholesterolemia, diabetes, smoking, hypertension, and the extent of coronary artery disease. OUTCOMES MEASURED: The 8 outcomes analyzed were angiogram, angioplasty, stent placement, coronary artery bypass grafting (CABG), mortality, time in the intensive care unit, total length of stay, and combined catheterization procedures. RESULTS: After adjusting for 7 confounding variables, we found no significant differences between men and women for mortality, ICU time, total hospital time, stent placement, angiogram, angioplasty, or combined catheterization procedures. Men had significantly more CABG (relative risk [RR] 1.96, P <.01). Among patients who underwent CABG (N = 204), men had significantly more 3-vessel coronary disease (RR 1.44, P <.01) and left main coronary artery disease greater than 50% (RR 1.58, P <.01). Once we had controlled for the extent of coronary artery disease, we found no difference between the sexes for CABG. CONCLUSIONS: During hospitalization after an MI, most cardiovascular outcomes and process measures are the same for men and women. The greater frequency of CABG in men than in women is explained by men's greater frequency of 3-vessel and advanced left-main coronary disease.     

Does volume really affect outcome? Lessons from the evidence

There is a prevailing consensus that the quality of health services can be improved by concentrating care in the hands of those providers who carry out larger volumes of activity. The substantial research literature indicates a positive volume-quality relationship. However, these conclusions are largely based on observational studies using administrative databases which are poorly adjusted for case mix. Better control for confounding shows that volume-quality effects in several cases may be an artefact. The research is also difficult to interpret because of the limited measurement of outcomes, poor analysis of the relative contributions of the clinician and the hospital levels, and the lack of clarity about the direction of cause and effect. Most research is insufficiently reliable to inform policy on the use of volume for credentialling or for the re-configuration of services.     

Does geographic access to primary healthcare influence the detection of hepatitis C?

Recent work in France has suggested that poor geographic access to primary healthcare may have a negative influence upon detection rates of the hepatitis C virus. Topography and poor infrastructure can exacerbate geographic remoteness, while the stigma surrounding hepatitis C and intravenous drug use may also discourage healthcare-seeking behaviour in rural communities with limited choice of general practitioner. No similar study has been conducted in the UK, where detection rates of hepatitis C are also low. Moreover, the previous French findings did not adjust for the uneven spatial distribution of HCV prevalence and associated risk factors, which raises the possibility that the reported travel-time associations were a reflection of greater hepatitis C prevalence in urban areas (where the travel-times to primary healthcare are short) and not an effect of geographic access to primary healthcare. Using geographic information systems, Poisson regression and a dataset from Tayside (Scotland), we explored whether lower rates of hepatitis C detection were associated with higher travel-times to primary healthcare. We tested whether any travel-time effects remained once the models were adjusted for deprivation, by controlling for the spatial variation of some of the known risk factors of hepatitis C infection. Separate models were calculated according to patient history of opiate substitution therapy to take account of people likely to have been infected through intravenous drug use. Rates of detected hepatitis C were highest among males aged between 25 and 39 years. A statistically significant travel-time-decay effect was observed, though with notable attenuation for all patients after adjusting for deprivation. Further modelling identified a travel-time effect only for those who had received opiate substitution therapy. The absence of a similar effect in the non-opiate substitution therapy group indicates that selection effects, not causation, are the most likely explanation for the initial travel-time-decay effects. Thus, future studies of hepatitis C detection and geographic access to primary healthcare will need to consider ways of controlling for the uneven spatial distribution of HCV prevalence and associated risk factors beyond ecological measures of socioeconomic deprivation.     

Importance of Change Appraisal for Employee Well-being during Organizational Restructuring: Findings from the Finnish Paper Industry’s Extensive Transition

The global recession has forced the Finnish forest industry to carry out majorrestructuring activities. Employees have faced different kinds of restructuring, mainlyaimed at reducing staff and production. Many studies have shown the negative consequencesof restructuring on employee well-being by using negative, ill-health indicators. Our aimis to examine the extent to which change appraisal influences both the negative andpositive aspects of work-related well-being among employees who continue working in theorganization after the restructuring process. We also examine the role of different actors(top management, immediate supervisor, employees themselves) in how the change isappraised. The study investigated blue-collar employees working in the Finnish forestindustry during a period of extensive transition (2008–2009). All six participatingfactories underwent restructuring between baseline and the follow-up survey (n=369). Afteradjustment for gender, age and baseline well-being, negative change appraisal increasedthe risk of experiencing more stress and less work enjoyment. Negative change appraisalsthus also damaged the positive, motivational aspects of employee well-being. The resultsshowed the importance of offering employees the opportunity to participate in the planningof changes related to their work as regards positive change appraisal.     

Does age influence the intensity of care in a managed care organization?

The primary objective of this study was to determine whether an inverse relationship between age and the intensity of care prevailed in an elderly, functionally impaired population enrolled in a managed care organization. The secondary objective was to determine whether those who died during the study were treated more intensively than the survivors. A total of 278 enrollees in a managed care organization who were 75 years and over, had a severe functional disability, excessive hospital or Emergency Department use, volunteered to take part in a 2-year study. Seventy-seven clients died during the study. We calculated indices of outpatient care intensity and hospital care intensity for the study period. With minor exceptions, the results clearly show that, for this group of clients, the intensity of outpatient care was clearly, inversely related to age. The intensity of hospital care was also inversely related to age, thereby ruling out the hypothesis that it was being substituted for outpatient care. The results also clearly show that, for this population, those who died during the study period were treated more intensively than the survivors. We found strong support for our hypotheses. An investigation of the reasons for these findings was beyond the scope of our data.     

Does the type of treatment supporter influence tuberculosis treatment outcomes in Zimbabwe?

Zimbabwe National Tuberculosis Guidelines advise that direct observation of anti-tuberculosis treatment (DOT) can be provided by a family member/relative as a last resort. In 2011, in Nkayi District, of 763 registered tuberculosis (TB) patients, 59 (8%) received health facility-based DOT, 392 (51%) received DOT from a trained community worker and 306 (40%) from a family member/relative. There were no differences in TB treatment outcomes between the three DOT groups, apart from a higher frequency rate of ‘no reported outcomes’ for those receiving family-based DOT. Family members should be trained to use a suitable DOT support package.     

Does an interaction between smoking and drinking influence the risk of Alzheimer's disease? Results from three Canadian data sets

Investigation of the relationship of smoking and drinking to Alzheimer's disease (AD) may advance research on the cause of AD and provide a basis for treatment. Pharmacological mechanisms for an involvement of smoking and drinking are plausible but epidemiologic reports are inconsistent. Evidence of behavioural and physiological interactions suggests that tobacco and alcohol use may not only individually affect AD, but may also modify each other's effects. A modelling strategy was developed to examine the interaction between smoking and drinking on the risk of AD. Three Canadian data sets were analysed: the University of Western Ontario Dementia Study (UWODS) (n=363); the Canadian Study of Health and Aging (CSHA) (n=516), and the database from the Clinic for Alzheimer Disease and Related Disorders at the Vancouver Hospital and Health Sciences Centre, University of British Columbia site (UBC) (n=843). Multiple logistic regression models were adjusted for the potential confounders age, age squared, sex, education, family history of dementia, head injury and hypertension. Analysis of the CSHA provided evidence consistent with the hypothesis that smoking and drinking influence each other's effects on AD, with smoking reducing the risk of AD among drinkers. A similar interaction was marginally significant (p=0.052) in the UWODS data set, but not significant in the UBC data. Extension of these analyses, particularly in longitudinal studies and within genetic risk groups, is needed to determine whether this interaction can be replicated. If so, research on the biological interactions of nicotine and alcohol may provide a basis for the development of therapeutic interventions as well as providing clues to the cause of this disorder.