Amanda L. Golbeck

The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions.

OBJECTIVES The purpose of this study was to implement and evaluate the effectiveness of a long-term tobacco use prevention program for junior high school students that used college undergraduate change agents and telephone boosters. METHODS A psychosocial intervention combining refusal skills training, contingency management, and other tobacco use prevention methodologies such as telephone and mail boosters was implemented in 11 junior high schools in San Diego County, California. Eleven other junior high schools served as controls. Of the 2668 participants, 57% were White/non-Hispanic, 24% were Hispanic, and 19% were of other racial/ethnic groups. College undergraduates served as change agents for both the classroom and booster interventions, the latter of which was delivered in the third (ninth-grade) year of the program. RESULTS At the end of the third year, the prevalence of tobacco use within the past month was 14.2% among the intervention students and 22.5% among the controls, yielding an odds ratio of 0.71 for analysis at the school level. CONCLUSIONS Both college undergraduate change agents and direct one-to-one telephone interventions appear to provide cost-effective tobacco-related behavior modification.

Amyotrophic Lateral Sclerosis and Occupational Heavy Metal Exposure: A Case-Control Study

A retrospective case-control study of occupational heavy metal exposure was conducted using 66 amyotrophic lateral sclerosis (ALS) patients and 66 age- and sex-matched controls. Cases were ascertained primarily through a neurology support and research clinic. The self-administered questionnaire probed potential exposure to nine heavy metals: aluminum, lead, lead alkyl, magnesium, manganese, mercury, mercury alkyl, nickel and selenium. Using McNemars test and a Mantel Haenszel extended analysis, no association was found between heavy metal exposure and the pathogenesis of ALS in this patient population. Demographic factors, fracture history, immunizations, travel and other variables were similar in ALS patients and controls.

Complexity of medication use in the Veterans Affairs healthcare system: Part I: Outpatient use in relation to age and number of prescribers.

Context: Multiple medication use is associated with an increased incidence of adverse drug-drug interactions (DDIs), medication errors, noncompliance, hospitalization, and healthcare costs. Drugs acting systemically or gastrointestinally (“SG” drugs) are of particular concern because of their potential to interact. A better understanding is needed of the relationship between multiple medication use, particularly of SG drugs, and age, number of prescribers, and common drug regimens. Objective: to determine the levels of multiple SG medication use in relation to age, number of prescribers, and common drug regimens in an outpatient population served by U.S. Veterans Integrated Service Network 15 (VISN 15). Design, setting, and participants: cross-sectional analysis of the subset of 5,003 currently active patients from a stratified random sample of 7,000 potentially active outpatients (1,000 each from 7 sites comprising VISN 15) selected from the prescription database on a single day. Main outcome measures: number of SG drugs/patient; number and frequency of SG drug entities and regimens. Results: Most patients (97%) were dispensed at least one SG drug: 80% received ≥2 SG drugs, of which 42% received 2–4 SG drugs, 24%, 5–7 SG drugs, and 14%, ≥8 SG drugs. 394 different SG drugs were dispensed, only 88 of which occurred in 1% or more of patients. A significant increase (p < 0.0001) in level of multiple medication use occurred with increasing age and number of prescribers. Proportions of patients receiving 8 or more SG drugs approximately doubled with each additional prescriber, up to 4 or more prescribers. No drug regimen containing 2 or more drugs occurred in 1% or more of patients; 71% of patients were receiving a unique drug regimen (based on specific SG drugs without regard to dose or administration schedule). Conclusions: The uniqueness of SG drug regimens suggests no single prescriber could have extensive clinical experience with even a small fraction of the drug regimens patients receive. These findings suggest that potential DDIs cannot be predicted based on occurrence of common drug regimens in a general patient population. A follow-up study (reported separately) investigated whether common drug regimens can be identified by selecting for a specific drug treatment (e.g., an antidepressant). The improved ability to predict DDIs is particularly relevant for psychiatric patients, who are at increased risk for DDIs because of greater frequency of multiple medication use. In addition, DDIs may present in this population in ways that mimic worsening of primary symptoms, which may lead to increased doses of the medication that is actually responsible for the problem, causing still more toxicity.

Epidemiology of Head Trauma and Neurocognitive Impairment in a Multi-Ethnic Population

This study tested two hypotheses. These were: (1) that mild cognitive impairment of the type that may characterize early-onset dementia of the Alzheimer type varies by ethnic group among the noninstitutionalized elderly, and (2) that head trauma is a risk factor associated with the development of this disease. The study sample consisted of a cohort of 2,105 Black, Mexican-American and White subjects aged 45 years and over at baseline in 1985-1987 in San Diego, Calif. Intellectual functioning was measured by Pfeiffers Short Portable Mental Status Questionnaire. Percent prevalence of test failure after Pfeiffers adjustment for education and ethnicity was highest for Whites (5.7%, CI = 4.26, 7.57) and lowest for Blacks (1.3%, CI = 0.61, 2.63), with Mexican-Americans intermediate (3.5%, CI = 2.28, 5.29). The difference between Blacks and Whites was statistically significant at the 0.05 level. Females failed more often (4.2%, CI = 3.15, 5.56) than males (3.1%, CI = 2.13, 4.47) across all ethnic groups, but the difference was not statistically significant after Pfeiffers adjustment for education and ethnicity. Self-reported head traumas and other possible risk factors for dementia of the Alzheimer type were examined by logistic regression in a case-control analysis. A statistically significant association (OR = 8.577, CI = 3.056, 24.064) was noted for those with mild intellectual impairment who reported head traumas in a multivariate environment.

Timeline Follow-Back Versus Global Self-Reports of Tobacco Smoking: A Comparison of Findings With Nondaily Smokers

Methods assessing nondaily smoking are of concern because biochemical measures cannot verify self-reports beyond 7 days. This study compared 2 self-reported smoking measures for nondaily smokers. A total of 389 college students (48% women, 96% White, mean age=19 years) smoking between 1 and 29 days out of the past 30 completed computer assessments in 3 cohorts, with the order of administration of the measures counterbalanced. Values from the 2 measures were highly correlated. Comparisons of timeline follow-back (TLFB) with the global questions for the total sample of nondaily smokers yielded statistically significant differences (p<.001), albeit small, between measures with the TLFB resulting on average in 2.38 more total cigarettes smoked out of the past 30 days, 0.46 fewer smoking days, and 0.21 more cigarettes smoked per day. Analyses by level of smoking showed that the discordance between the measures differed by frequency of smoking. Global questions of days smoked resulted in frequent reporting in multiples of 5 days, suggesting digit bias. Overall, the 2 measures of smoking were highly correlated and equally effective for identifying any smoking in a 30-day period among nondaily smokers.

Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients.

Context: A previous study, described in Part I of this report, found that 71% of a sample of 5,003 general outpatients in the Veterans Affairs healthcare system were receiving a unique drug regimen (i.e., total specific drug entities regardless of dose, formulation, or administration schedule). The simplest regimens contained only one drug, while the most complex regimens exceeded 20 different drugs. The purpose of the present study was to determine if patients receiving a specific therapeutic class of medications (e.g., antidepressants) have more homogeneous drug regimens. Objective: to examine the extent and complexity of multiple medication use in younger and older adult outpatients receiving antidepressants compared with those not receiving antidepressants. The study focused on drugs that act systemically or gastrointestinally and hence have the potential to interact. Design, setting, and participants: Two subsets of stratified random samples of outpatients selected from prescription databases of U.S. Veterans Integrated Service Network 15. The first group involved 1,991 patients deemed to be on antidepressants (AD patients): 891 aged < 60 years and 1,100 aged ≥ 60 years. The second group involved 3,732 patients who had received no antidepressants within the previous 365 days but who had a supply of at least one other current prescription (NoAD patients): 1,195 aged < 60 years and 2,535 aged ≥ 60 years; 2 missing age information. Main outcome measures: number of drugs, frequency of drug regimens, level of multiple medication use including and excluding antidepressants. Results: Younger AD patients received 3 more drugs than younger NoAD patients. 23.6% of younger AD patients, versus 5.9% of younger NoAD patients, received ≥ 8 drugs. Older AD patients received 2 more drugs than older NoAD patients. 37.6% of older AD patients, versus 12.8% of older NoAD patients, received ≥ 8 drugs. In both the AD and NoAD groups, 62%–96% of patients of all ages were receiving unique drug regimens. Each drug regimen containing 2 or more drugs occurred in fewer than 1% of patients. Conclusions: AD patients were receiving more complex drug regimens and had a higher frequency of unique drug regimens than NoAD patients, even when the results were adjusted for age group and number of prescribers. The high prevalence of unique drug combinations in all patient groups in this study indicates that clinicians in this system have only limited experience with the total effects of all of the medications their patients are receiving and thus cannot rely on experience to guard against adverse multi-drug interactions. This fact is a particular concern with psychiatric medications because adverse DDIs involving these medications can mimic psychiatric symptoms and may therefore be more difficult to detect.

Amyotrophic lateral sclerosis and history of skeletal fracture A case‐control study

A retrospective case-control study was conducted, using 66 amyotrophic lateral sclerosis (ALS) patients and 66 closely matched controls. Cases were ascertained primarily through a neurology clinic. A self-administered questionnaire probed for history of skeletal fractures. Using McNemars test, no association was found between history of skeletal fracture and pathogenesis of ALS. No predilection for the head, neck, or spine was demonstrated. The extremities accounted for most fracture sites in cases and controls. Among cases, 68% of the fractures occurred before diagnosis, 58% occurring more than 10 years before diagnosis of ALS.

Correlating reading comprehension and health numeracy among adults with low literacy

OBJECTIVE Using the Test of Functional Health Literacy for Adults (TOFHLA), a pilot study was conducted to assess whether reading comprehension and numeracy scores sufficiently correlate in health contexts among adults with low literacy skills. METHODS The TOFHLA was administered to 144 adults with low literacy enrolled in a health literacy program prior to the start of coursework. Raw scores for reading and numeracy were calculated. Weighted numeracy scores were calculated and compared to raw reading comprehension scores. RESULTS Among 143 participants, 20% (n=28) had a higher numeracy score than reading comprehension score, while an additional 20% scored lower in numeracy than in reading comprehension. CONCLUSION This study found that reading comprehension and numeracy skill in the context of understanding health information do not necessarily correlate for specific disadvantaged groups. This finding calls attention to the need to further examine numeracy as a construct which is conceptually separate from reading comprehension, and highlights the importance of including a numerate component in health literacy evaluations. PRACTICE IMPLICATIONS The results of this study have important implications for medical decision-makers, health educators, and health promoters working with traditional methods of assessing health literacy.

Maternal alcoholism and anorexia nervosa: a possible association?

The use of modern epidemiological and biostatistical methods has been lacking in the research literature on anorexia nervosa. The present study utilized a retrospective case control design in which 40 cases of anorexia nervosa were matched to two separate control series, one being population based and one being clinic based. Odds ratio of 4.00 (p less than 0.006) and 7.67 (p less than 0.001) were obtained for family history of alcoholism and family history of psychological disorders, respectively, among the families of anorexia nervosa cases. The implications of this result for treatment planning and implementation are discussed.

Examination of a brief Smoking Consequences Questionnaire for college students.

This study examined the factor structure of a brief version of the Smoking Consequences Questionnaire-Adult (SCQ-A) among 315 college freshman and sophomore smokers. A comparison of results from two confirmatory factor analyses demonstrated that a nine-factor model provided superior fit to a four-factor model. Furthermore, results revealed a lack of factorial invariance of factor loadings for daily and nondaily smokers, and of latent mean structures for smoking category and gender. In addition, concurrent validity tests demonstrated that positive expectancies increased with smoking rate and nicotine dependence. These results and their implications are discussed.