Suzette Levenson

Effects of maternal marijuana and cocaine use on fetal growth

To investigate the effects on infants of the use of marijuana and cocaine during pregnancy and to compare the importance of urine assays with that of interviews in ascertaining drug use, we prospectively studied 1226 mothers, recruited from a general prenatal clinic, and their infants. On the basis of either interviews or urine assays conducted prenatally or post partum, 27 percent of the subjects had used marijuana during pregnancy and 18 percent had used cocaine. When only positive urine assays were considered, the corresponding values were 16 percent and 9 percent, respectively. When potentially confounding variables were controlled for in the analysis, the infants whose mothers had positive urine assays for marijuana, as compared with the infants whose mothers were negative according to both interviews and urine assays, had a 79-g decrease in birth weight (P = 0.04) and a 0.5-cm decrement in length (P = 0.02). Women who had positive assays for cocaine, as compared with nonusers, had infants with a 93-g decrease in birth weight (P = 0.07), a 0.7-cm decrement in length (P = 0.01), and a 0.43-cm-smaller head circumference (P = 0.01). To compare our findings with those of other investigators who did not use urine assays, we repeated the analyses, considering only self-reported use of marijuana (23 percent) and cocaine (13 percent). There were no significant associations between such use as determined by interviews alone and any of the measures of outcome. We conclude that the use of marijuana or cocaine during pregnancy is associated with impaired fetal growth and that measuring a biologic marker of such use is important to demonstrate the association.

A Randomized Trial of Treatment Options for Alcohol-Abusing Workers

BACKGROUND Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options. METHODS We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period. RESULTS All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment. CONCLUSIONS Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.

Project ASSERT: An ED-Based Intervention to Increase Access to Primary Care, Preventive Services, and the Substance Abuse Treatment System

STUDY OBJECTIVE To test the feasibility and effectiveness of Project ASSERT, an innovative program developed by us to facilitate access to the substance abuse treatment system and to primary care and preventive services for emergency department patients with drug- and alcohol-related health problems. METHOD Multicultural health promotion advocates (HPAs) were trained by ED personnel to screen patients using a health needs history, to administer a brief negotiated interview based on readiness-to-change principles, and to use an active referral process to capture the marginal capacity of the substance abuse treatment system. Outcome measures included (1) number of referrals to the substance abuse treatment system, (2) patient self-report of satisfaction with services received from Project ASSERT and utilization of treatment resources, and (3) changes in self-reported frequency of drug and alcohol use and in Drug Abuse Screening Test scores between enrollment and follow-up at 60 to 90 days. RESULTS Between March 1, 1995, and February 29, 1996, 7,118 adult ED patients were screened. Substance abuse was detected among 2,931 patients (41%), and 1,096 (37% of detected patients) were enrolled. A total of 8,848 referrals were made: 3,189 to primary care, 2,018 to a variety of substance abuse treatment services, 2,253 for smoking cessation, 339 for mammography, and 689 to other support services (eg, psychiatric nurse, social worker, battered womens advocate or shelter). Comparison of enrollment and follow-up scores for the 245 enrollees who kept a follow-up appointment demonstrated significant reductions, including a 45% reduction in severity of drug problem, a 56% reduction in alcohol use, and a 64% reduction in the frequency of drinking six or more drinks at one sitting. At follow-up, patients expressed satisfaction with Project ASSERT: 91% were satisfied with their referrals; 93% thought the HPAs explained things well; and 99% thought the HPAs respected them as individuals. Among the follow-up group, 50% self-reported that they had kept an appointment for treatment. CONCLUSION Project ASSERT is an innovative approach to link ED patients with the substance abuse treatment system and with primary care and other preventive services. Its success is further demonstrated by its adoption by Boston Medical Center as a funded ED value-added service.

Maternal Depression, Changing Public Assistance, Food Security, and Child Health Status

OBJECTIVE To examine the association of positive report on a maternal depression screen (PDS) with loss or reduction of welfare support and foods stamps, household food insecurity, and child health measures among children aged < or =36 months at 6 urban hospitals and clinics. METHODS A convenience sample of 5306 mothers, whose children <36 months old were being seen in hospital general clinics or emergency departments (EDs) at medical centers in 5 states and Washington, District of Columbia, were interviewed from January 1, 2000 until December 31, 2001. Questions included items on sociodemographic characteristics, federal program participation and changes in federal benefits, child health status rating, childs history of hospitalizations since birth, household food security status, and a 3-question PDS. For a subsample interviewed in the ED, whether the child was admitted to the hospital that day was recorded. RESULTS PDS status was associated with loss or reduction of welfare support and food stamps, household food insecurity, fair/poor child health rating, and history of child hospitalization since birth but not low child growth status measures or admission to the hospital at the time of ED visit. After controlling for study site, maternal race, education, and insurance type as well as child low birth weight status, mothers with PDS were more likely to report fair/poor child health (adjusted odds ratio [AOR]: 1.58; 95% confidence interval [CI]: 1.33-1.88) and hospitalizations during the childs lifetime (AOR: 1.20; 95% CI: 1.03-1.39), compared with mothers without PDS. Controlling for the same variables, mothers with PDS were more likely to report decreased welfare support (AOR: 1.52; 95% CI: 1.03-2.25), to have lost food stamps (AOR: 1.56; 95% CI: 1.06-2.30), and reported more household food insecurity (AOR: 2.69; 95% CI: 2.33-3.11) than mothers without PDS. CONCLUSION Positive maternal depression screen status noted in pediatric clinical samples of infants and toddlers is associated with poorer reported child health status, household food insecurity, and loss of federal financial support and food stamps. Although the direction of effects cannot be determined in this cross-sectional survey, child health providers and policy makers should be aware of the potential impact of maternal depression on child health in the context of welfare reform.

Foreign-born and US-born black women: differences in health behaviors and birth outcomes.

We studied health behaviors and birth outcome among 201 foreign-born and 616 US-born Black women receiving prenatal care at Boston City Hospital. Foreign-born women had better pre-pregnancy nutritional status and prenatal health behaviors, and their infants had greater intrauterine growth. Black women are not a homogeneous group; culture and ethnicity, in addition to other variables, must be considered in the study of their birth outcomes.

Sunbathing habits and sunscreen use among white adults: results of a national survey.

OBJECTIVES This study assessed current levels of sunbathing and sunscreen use in the United States. METHODS From a general-population telephone survey of aquatic activities among adults in 3042 US households, we examined responses by the 2459 Whites. RESULTS Most adults (59%) reported sunbathing during the past year, and 25% reported frequent sunbathing. Of the subsample who reported sunbathing during the month before the interview, 47% routinely used sunscreen. Of these individuals, almost half did not use sunscreens with a solar protection factor of 15 or higher. CONCLUSIONS About a quarter of US White adults report frequent sunbathing, and only about a quarter of sunbathers use sunscreens at recommended levels. These results should help focus future sun protection educational efforts.

Barriers to Following the Supine Sleep Recommendation Among Mothers at Four Centers for the Women, Infants, and Children Program

OBJECTIVES. The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers. DESIGN/METHODS. We conducted face-to-face interviews with 671 mothers, 64% of whom were black, who attended Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. We used univariate analyses to quantify factors that were associated with choice of sleeping position and multivariate logistic regression to calculate adjusted odds ratios for the 2 outcome variables: “ever” (meaning usually, sometimes, or last night) put infant in the prone position for sleep and “usually” put infant in the supine position to sleep. RESULTS. Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position. CONCLUSIONS. We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.

Barriers to Following the Back-to-Sleep Recommendations: Insights From Focus Groups With Inner-City Caregivers

BACKGROUND African American infants have a higher incidence of SIDS and increased risk of being placed in the prone position for sleep. OBJECTIVE To determine new barriers and more information about previously identified barriers that interfere with adherence to the Back-to-Sleep recommendations among inner-city, primarily African Americans. DESIGN/METHODS We conducted 9 focus groups with caregivers of infants and young children from women, infants, and children centers and clinics in New Haven and Boston. Themes were identified using standard qualitative techniques. RESULTS Forty-nine caregivers participated, of whom 86% were African American, 6% were Hispanic, 4% were white, and 4% were other. Four themes were identified: 1) SAFETY: Participants chose the position for their infants based on which position they believed to be the safest. Some participants did not choose to put their infants in the supine position for sleep because they feared their infants would choke; 2) Advice: Participants relied on the advice of more experienced female family members. Health care providers were not uniformly a trusted source of advice; 3) Comfort: Participants made choices about their infants sleeping positions based on their perceptions of whether the infants appeared comfortable. Participants thought that their infants appeared more comfortable in the prone position; 4) Knowledge: Some participants had either limited or erroneous knowledge about the Back-to-Sleep recommendations. CONCLUSIONS We identified multiple barriers to adherence to recommendations regarding infant sleep position. Data obtained from these focus groups could be used to design educational interventions aimed at improving communication about and adherence to the Back-to-Sleep recommendations.

Early experience with the first pre-connected 3-piece inflatable penile prosthesis: the Mentor Alpha-1.

The aim of this clinical investigation was to obtain preliminary treatment outcome data concerning the Mentor Alpha-1, the first 3-piece inflatable penile prosthesis with pre-connected tubing between the pump and the penile cylinders. The study was designed to be the first multi-institutional treatment outcome report for any clinically available penile prosthesis with data analysis to be independent of the participating surgeons. A total of 12 board-certified urologists of mixed surgical training backgrounds and practices implanted the Alpha-1 device in 112 consecutive patients. With a mean of 27 +/- 5 months of followup the surgical complication rate included a 4% mechanical malfunction, 2% infection rate and 9% reoperation rate. Patient experience with the implanted device was computed from information on 96 of the 112 patients who returned a questionnaire. Of the patients 82% stated that the device fulfilled expectations as a treatment for impotence and 83% had improved sexual intercourse by 8 weeks after implantation. Patient satisfaction was computed on a scale of 12 equally weighted interrelated variables. Of the patients 77% recorded 9 or more cumulative satisfaction points. Patient and physician questionnaire data were analyzed for their relation to the cumulative prosthesis satisfaction score. A significant difference in cumulative scores was found for physician reported long-term postoperative problems (mean satisfaction score 8.1 for patients with problems versus 10.2 for patients without problems, p = 0.018). The Alpha-1, with its feature of pre-connected tubing, is a reliable 3-piece inflatable penile prosthesis associated with a high level of patient satisfaction.

Mitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trial.

AIM To assess the effectiveness of a sexual risk reduction intervention in the Russian narcology hospital setting. DESIGN, SETTING AND PARTICIPANTS This was a randomized controlled trial from October 2004 to December 2005 among patients with alcohol and/or heroin dependence from two narcology hospitals in St Petersburg, Russia. INTERVENTION Intervention subjects received two personalized sexual behavior counseling sessions plus three telephone booster sessions. Control subjects received usual addiction treatment, which did not include sexual behavior counseling. All received a research assessment and condoms at baseline. MEASUREMENTS Primary outcomes were percentage of safe sex episodes (number of times condoms were used / by number of sexual episodes) and no unprotected sex (100% condom use or abstinence) during the previous 3 months, assessed at 6 months. FINDINGS Intervention subjects reported higher median percentage of safe sex episodes (unadjusted median difference 12.7%; P = 0.01; adjusted median difference 23%, P = 0.07); a significant difference was not detected for the outcome no unprotected sex in the past 3 months [unadjusted odds ratio (OR) 1.6, 95% confidence interval (CI) 0.8-3.1; adjusted OR 1.5, 95% CI 0.7-3.3]. CONCLUSIONS Among Russian substance-dependent individuals, sexual behavior counseling during addiction treatment should be considered as one potential component of efforts to decrease risky sexual behaviors in this HIV at-risk population.