M. Kathleen Clark

An epidemiologic analysis of pain in the elderly: the Iowa 65+ Rural Health Study

Despite acknowledgment that pain is likely to be a major problem for many older adults, it is difficult to accurately estimate the frequency of pain problems for this population because of the lack of systematic epidemiological investigation. This article reports a study of the prevalence and nature of pain in a population of 3,097 rural persons 65 years and older (the Iowa 65+ Rural Health Study). Of the subjects, 86% reported pain of some type in the year prior to the interview, and 59% reported multiple pain complaints. Joint pain was the most prevalent site of pain reported, followed by night leg pain, back pain, and leg pain while walking. As reported severity of pain increased, there was a corresponding increase in impact on daily activities.

Posttraumatic stress disorder and physical comorbidity among female children and adolescents: Results from service-use data

Objective. In adults, posttraumatic stress disorder (PTSD) is associated with adverse health outcomes and high medical utilization and cost. PTSD is twice as common in women and is associated with increased risk for a range of diseases, chronic conditions, and reproductive-health problems. Little is known about the health effects of PTSD in children. The purpose of this study was to explore patterns of physical comorbidity in female children and adolescents with PTSD by using population data. Methods. This study was a cross-sectional, descriptive epidemiologic case-control analysis of a Midwestern states Medicaid eligibility and paid-claims data for girls (0–8 years old) and teens (9–17 years old). Data were from 1994–1997. All those with the PTSD diagnostic code were compared with randomly selected controls in relation to 3 sets of outcomes: (1) International Classification of Diseases, Ninth Revision (ICD-9) categories of disease; (2) chronic conditions previously associated with sexual trauma and PTSD in women; and (3) reproductive-health problems. Analyses included bivariate odds ratios (OR) and logistic-regression models that control for the extent of insurance coverage and the independent associations of victimization and psychiatric comorbidity with the 3 sets of outcomes. The mental health covariate was categorical to allow consideration of a range of severity. There were 4 categories for the young girls: neither PTSD nor depression, PTSD without depression, depression without PTSD, and PTSD + depression. For the adolescent analysis, a fifth category reflecting a “complex PTSD” was added, defined as having PTSD complicated by a dissociative disorder or borderline personality disorder diagnosis. Results. There were 647 girls and 1025 adolescents with the PTSD diagnosis. Overall, PTSD was associated with adverse health outcomes in both age strata. Victimization was sometimes independently associated with adverse health outcomes, but PTSD often was a mediator, especially in the adolescent age stratum. The importance of PTSD diagnosis as a predictor of the ICD-9 categories of disease or chronic conditions seemed to increase with age. In the younger age stratum, the increased bivariate ORs of significant associations with PTSD ranged from 1.4 for digestive disorders to 3.4 for circulatory disorders. Among younger girls, PTSD diagnosis was associated with significantly greater bivariate odds for 9 of the 12 ICD-9 categories of disease but not for neoplasms, blood disorders, or respiratory disorders and with threefold increased odds for chronic fatigue. They also had 1.8 times greater odds for sexually transmitted infections, some of which could be from congenital transmission in this age group, which includes infants. In the multivariate models for the young girls, the mental health variable seemed to mediate the relationship between victimization and increased odds of infectious and parasitic diseases, endocrine/metabolic/immune disorders, circulatory diseases, skin and cutaneous tissue disorders, and having any 1 of the 5 chronic conditions. The mental health categories that were significantly associated with health outcomes varied across the conditions. There were no health outcomes in which the depression-without-PTSD category was the only one significantly associated with the outcome condition. Circulatory and musculoskeletal disorders were significantly associated with all 3 of the mental health categories. Having any 1 of the 5 chronic conditions was significantly associated only with simple PTSD (PTSD without depression). Genitourinary disorders and signs/symptoms/ill-defined conditions were significantly associated with both simple and comorbid PTSD. PTSD with comorbid depression, the most severe of the mental health categories in this younger age group, was the only category associated with the endocrine/metabolic/immune disorders and skin disorders outcomes. In the adolescent age stratum, the bivariate ORs significantly associated with PTSD ranged from 2.1 for blood disorders to 5.2 for irritable bowel syndrome. Adolescents with PTSD were nearly twice as likely to have a sexually transmitted infection and 60% more likely to have cervical dysplasia. However, their rate of pregnancy was lower (23% vs 31%), a one-fourth decreased odds. In the adolescent group, only 4 outcomes (nervous system/sense organ, digestive, and genitourinary disorders and signs/symptoms/ill-defined conditions) remained statistically significantly associated with victimization after the mental health variable was added, suggesting an additive model of risk for these outcomes but a mediating role for PTSD in relation to the majority of the health outcomes. Among the adolescent girls, the range of ORs for the ICD-9 and chronic-condition diagnoses generally increased across the categories of the mental health variable in a dose-response pattern. Compared with adolescents with neither PTSD nor depression, those with PTSD without depression had statistically significant ORs from 1.5 to 3.6. Those with depression without PTSD had statistically significant ORs from 1.9 to 4.4. The significant ORs for those with PTSD comorbid with depression were from 2.3 to 6.6, and those in the complex-PTSD category had significant ORs of between 2.5 and 14.9. Only blood disorders seemed to be more strongly associated with depression alone than with the comorbid and complex forms of PTSD. The simple-PTSD category was not significantly associated with blood disorders, chronic pelvic pain, fibromyalgia, or dysmenorrhea. Depression without PTSD was not significantly associated with chronic pelvic pain or fibromyalgia. Fibromyalgia was only significantly associated with complex PTSD. Conclusions. In young girls who receive Medicaid benefits, PTSD was associated with increased odds of a range of adverse health conditions. The pattern and odds of physical comorbidity among adolescent recipients with PTSD was nearly as extensive as that seen in adult women. Overall, the pattern observed suggests that objective disease states (eg, circulatory problems, infections) may be associated with PTSD to an extent nearly as great as that of PTSD with more subjective somatic experience of loss of wellness. Using the concepts of allostatic load and allostatic support, professionals who work with children and adolescents may be able to decrease the toll that traumatic stress takes on health even if available interventions can only be thought of as supportive and fall short of completely preventing trauma exposure or completely healing posttraumatic stress. Clinical research to extend these exploratory findings is warranted.

Magnitude and variability of sequential estradiol and progesterone concentrations in women using depot medroxyprogesterone acetate for contraception

OBJECTIVE To describe the magnitude and variability of sequential serum estradiol and progesterone concentrations throughout one depot medroxyprogesterone (DMPA) injection interval. DESIGN Prospective study. SETTING Family planning and womens health clinics. PATIENT(S) Thirty-one women, ages 19 to 46, using DMPA for contraception. INTERVENTION(S) Serum for estrogen and progesterone was collected weekly throughout one DMPA injection interval. MAIN OUTCOME MEASURE(S) Serum estradiol and progesterone concentrations; estradiol patterns produced from data plotted across the entire DMPA injection interval. RESULT(S) The average daily estradiol concentrations ranged from 7.9 to 69.1 pg/mL, with a mean of 18.9 +/- 12.9 and a median of 15.4 pg/mL. Average daily progesterone concentrations ranged from 0.14 to 1.1 ng/mL, with a mean of 0.40 +/- 0.19 ng/mL and a median of 0.36 ng/mL. Two general patterns of estradiol concentrations were identified. One pattern, observed in approximately one third of the participants, reflected estradiol concentrations that were extremely low (mean, 12.7 +/- 3.6 pg/mL; median, 13.4 pg/mL) and consistently flat across the DMPA injection interval. The second pattern, seen in the remaining participants, reflected estradiol concentrations that were higher (mean, 22.2 +/- 14.9 pg/mL; median, 17.3 pg/mL) and quite variable. CONCLUSION(S) This study demonstrated that estradiol concentrations were lower than the 40 to 50 pg/mL reported in most studies and, for the majority of women, varied substantially across the DMPA injection interval.

Body mass index misclassification of obesity among community police officers

Occupational health nurses are at the forefront of obesity assessment and intervention and must be aware of potential inaccuracies of obesity measurement. The purpose of this study was to identify the prevalence of obesity among a sample of 84 male police officers 22 to 63 years old and determine the accuracy of body mass index (BMI) in estimating obesity compared to body fat percent (BF %). BMI identified 39.3% of the participants as obese, compared to 70.2% by BF %. BMI misclassified normal-weight officers as obese or overweight and obese officers as normal 48.8% (n = 41) of the time. The two misclassified groups had similar average BMIs but significantly different BF %. BMI was not an accurate measure of obesity among adult males. BMI underestimated the true prevalence of obesity and could represent a missed opportunity for early intervention and disease prevention.

Emergency Contraception in Iowa Pharmacies Before and After Over-the-Counter Approval

OBJECTIVES To compare availability of emergency contraception in Iowa pharmacies, before and after the U.S. Food and Drug Administration (FDA) approved over-the-counter sales and identify reasons why over-the-counter, emergency contraception might still not be available in some Iowa pharmacies. DESIGN AND SAMPLE Secondary analysis of data collected for an existing, descriptive study. A total of 906 pharmacies were identified; 405 (56.8%) pharmacies participated before, and 308 (43.2%) after the FDA policy change. MEASURES Data collected via a scripted telephone survey. RESULTS After the FDA changed its policy and allowed over-the-counter sales of emergency contraception, the percentage of Iowa pharmacies offering emergency contraception increased from 57.8% to 70%. In the before sampling, 67.5% reported a perceived lack of demand as the primary reason for not carrying emergency contraception 66.7% reported this rationale in the after group. Other reasons included store policy, and moral, religious, or personal reasons. Pharmacists were surprisingly uninformed about the action of emergency contraception; before the FDA approved over-the-counter sales 53% believed the drugs primarily worked by blocking implantation of a fertilized egg. Indeed, even after FDA approved over-the-counter sales, 38% of pharmacists still believed that emergency contraception was comparable to an abortifacient. In addition, before the policy changed, 43.8% of pharmacists accepted emergency contraception as safe for teenagers; this percentage fell to 27.9% after the policy change. CONCLUSIONS Significant increases in the carrying of emergency contraception suggest the policy did succeed in increasing access. Despite this, barriers to access exist. Further research should explore why pharmacies might not carry emergency contraception.

Worksite Physical Activity Intervention for Ambulatory Clinic Nursing Staff

Health behaviors, including physical activity (PA), of registered nurses (RNs) and medical assistants (MAs) are suboptimal but may improve with worksite programs. Using a repeated-measures crossover design, the authors explored if integrating a 6-month worksite non-exercise activity thermogenesis (NEAT) intervention, with and without personalized health coaching via text messaging into workflow could positively affect sedentary time, PA, and body composition of nursing staff without jeopardizing work productivity. Two ambulatory clinics were randomly assigned to an environmental NEAT intervention plus a mobile text message coaching for either the first 3 months (early texting group, n = 27) or the last 3 months (delayed texting group, n = 13), with baseline 3-month and 6-month measurements. Sedentary and PA levels, fat mass, and weight improved for both groups, significantly only for the early text group. Productivity did not decline for either group. This worksite intervention is feasible and may benefit nursing staff.

Knowledge and Use of Emergency Contraception in College Women

Despite the value of emergency contraception (EC) in reducing unintended pregnancy, use in college women has not been widely studied. This exploratory descriptive study, using a web-based survey, described knowledge and use of EC in 2,007 college women and identified associations between selected personal characteristics and EC use. Most women (72.2%) knew EC could be obtained over the counter and was most effective within 72 hr of intercourse (93%). Women inaccurately thought EC was effective through the first trimester of pregnancy (87.1%) and could cause birth defects (27.8%). Among sexually active women, 37% reported use. Experiencing a false alarm pregnancy, knowing that EC was available over the counter, and being Asian/Pacific Islander were positively associated with use. Additional studies should explore the utility of EC in other populations and efforts should be stepped up to provide accurate information about access and mechanism of use.

Assisting Older Persons With Adjusting to Hearing Aids

This intervention study tested the feasibility and initial effect of Hearing Aid Reintroduction (HEAR) to assist persons aged 70 to 85 years adjust to hearing aids. Following this 30-day intervention, hearing aid use increased between 1 and 8 hr per day with 50% of participants able to wear them for at least 4 hr. Hearing aid satisfaction improved from not satisfied to satisfied overall. The study demonstrated that HEAR is feasible and could improve hearing aid use of a substantial number of older persons who had previously failed to adjust to their hearing aids and had given up. However, further testing among a larger and more diverse population is needed to better understand the effectiveness and sustainability of the intervention.

Disordered eating behaviors and bone-mineral density in women who misuse alcohol.

Because lower bone-mineral density is one potential physiological consequence of eating disorders and chronic alcohol misuse, the risk for osteoporosis may be compounded in women who have both conditions. This study investigated the frequency of eating disorders in 25 women who misuse alcohol and compared bone-mineral density between those with and without multiple disordered eating behaviors. Disordered eating behaviors were assessed through the EAT-26 (Eating Attitudes Test) and a structured interview addressing binge eating, purging, and other weight-control behaviors. Bone-mineral density was measured using dual energy x-ray densitometry. Although only one woman met the DSM-III-R criteriafora current eatingdisorder, 12% had past histories suggestive of anorexia nervosa and 40% had multiple disordered eating behaviors with bulimic features. Bone-mineral density of the femoral neck was 9.3% greater in women with multiple disordered eating behaviors (p < .05).