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Background: Immune-modifying medications are widely available and recognized as valuable by most gastroenterologists. However, approximately 40% of patients with Crohn's disease (CD) do not comply with regimens using these medications, resulting in complications, hospitalization, and surgeries. We sought to identify factors that motivate adherence or nonadherence with medication recommendations for CD., Methods: We conducted qualitative interviews with patients living with CD who were identified as adherent or nonadherent to immune-modifying medication recommendations by their treating gastroenterologist. Semistructured interview guides were developed based on an established framework for understanding health behaviors. We conducted content analysis of the resulting qualitative data using an inductive-deductive approach to identify emergent themes that influence medication decision-making., Results: Twenty-five patients with CD completed interviews for this study. Interviews were independently coded and analyzed for thematic content. Two broad domains emerged comprising (1) themes reflected in the Theoretical Domains Framework and (2) novel themes specific to medication decision-making in CD. Adherent patients conveyed a sense of trust in science and healthcare provider expertise, while nonadherent patients were more likely to express beliefs in their ability to self-manage CD, concern about risks associated with medication, and a general ambivalence to treatment., Conclusions: There are clear cognitive, behavioral, and relational factors that guide patients' medication-related decision-making. Several of the factors share features of other behavioral change and decision-making processes, while others are specific to the experience of patients with CD. A fuller understanding of these factors is essential to developing effective behavioral interventions to improve adherence to evidence-based treatment recommendations., (© The Author(s) 2023. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Rural healthcare has unique characteristics that affect the dissemination and implementation of evidence-based interventions. Numerous theories, models, and frameworks have been developed to guide implementation of healthcare interventions, though not specific to rural healthcare. The present scoping review sought to identify the theories, models, and frameworks most frequently applied to rural health and propose an approach to rural health research that harnesses selected constructs from these theories, models, and frameworks. This resulting synthesis can serve as a guide to researchers, policy makers, and clinicians seeking to employ commonly used theories, models, and frameworks to rural health., Methods: We used the Scopus abstract indexing service to identify peer-reviewed literature citing one or more of theories, models, or frameworks used in dissemination and implementation research and including the word "rural" in the Title, Abstract, or Keywords. We screened the remaining titles and abstracts to ensure articles met additional inclusion criteria. We conducted a full review of the resulting 172 articles to ensure they identified one or more discrete theory, model, or framework applied to research or quality improvement projects. We extracted the theories, models, and frameworks and categorized these as process models, determinant frameworks, classic theories, or evaluation frameworks., Results: We retained 61 articles of which 28 used RE-AIM, 11 used Community-Based Participatory Research (CBPR) framework, eight used the Consolidated Framework for Implementation Research (CFIR), and six used the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS). Additional theories, models, and frameworks were cited in three or fewer reports in the literature. The 14 theories, models, and frameworks cited in the literature were categorized as seven process models, four determinant frameworks, one evaluation framework, and one classic theory., Conclusions: The RE-AIM framework was the most frequently cited framework in the rural health literature, followed by CBPR, CFIR, and iPARIHS. A notable advantage of RE-AIM in rural healthcare settings is the focus on reach as a specified outcome, given the challenges of engaging a geographically diffuse and often isolated population. We present a rationale for combining the strengths of these theories, models, and frameworks to guide a research agenda specific to rural healthcare research., Systematic Review Registration: https://osf.io/fn2cd/., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Brady, Lyons, Stevens, Godzik, Smith, Bagley, Vitale and Bernstein.)

Purpose: Intravenous push antibiotics can serve as an alternative to intravenous piggyback antibiotics while providing the same pharmacodynamics and adverse effect profile, easing shortage pressures and decreasing order to administration time, as well as representing a potential cost savings. The purpose of this study was to determine whether intravenous push antibiotics could decrease the time from an order to the start of administration compared to piggyback antibiotics in emergency departments. This study also measured the cost savings of antibiotic preparation and administration and assessed nursing satisfaction when using intravenous push antibiotics., Methods: Sample instances of use of intravenous push and piggyback antibiotics were identified. Patients were included if they were 18 years of age or older and received at least a single dose of intravenous push or piggyback ceftriaxone, cefepime, cefazolin, or meropenem in one of the institution's emergency departments. The primary outcome of the study was to compare the time from the order to the start of administration of intravenous push vs piggyback antibiotics. The secondary outcome was to compare the cost of antibiotic preparation for the 2 methods., Results: The intravenous push and piggyback groups each had 43 patients. The time from the order to the start of administration decreased from 74 (interquartile range, 29-114) minutes in the piggyback group to 31 (interquartile range, 21-52) minutes in the push group (P = 0.003). When the estimated monthly cost savings for ceftriaxone, cefepime, and meropenem were added together, across the emergency departments, an estimated $227,930.88 is saved per year when using intravenous push antibiotics., Conclusion: Intravenous push antibiotics decrease the time from ordering to the start of administration and result in significant cost savings., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: We examined the impact of health care workers' (HCWs) adjustment to the COVID-19 pandemic on their work-related attitudes and behaviors., Methods: HCWs ( n = 1468) participated in an observational longitudinal study in which they completed surveys of anxiety and occupational health between 2020 and 2021., Results: Most HCWs reported anxiety that was consistently below the diagnostic threshold (68%) or fell below the threshold within a year (16%). Others reported consistently high (14%) or increasing (2%) anxiety, especially women, younger HCWs, those with a weakened immune system, and allied health professionals. Consistently high or increasing anxiety was associated with poorer job satisfaction, work engagement, perceived supervisor support, burnout, and turnover intentions., Conclusions: Resources to support HCWs may be focused on those who report consistently high or increasing anxiety to minimize the effects of crises and disasters on the workforce., Competing Interests: Conflicts of interest: None declared., (Copyright © 2024 American College of Occupational and Environmental Medicine.)

Purpose: Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE., Methods: A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically., Results: Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers., Discussion: I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify and prioritize opportunities to improve the psychiatric boarding experience for youth awaiting admission or transfer to inpatient psychiatric care., Study Design: This study utilized an exploratory mixed methods design. The study team convened multidisciplinary stakeholder focus groups to discuss proposed hospital-based solutions to mental health boarding, potential psychosocial interventions deliverable during boarding, and outcomes measurement. Focus group responses were transcribed and analyzed to extract themes pertaining to these improvement opportunities. These results informed a follow-up survey which was then sent to the stakeholders to rate the feasibility and importance of modifications using a modified RAND-UCLA Appropriateness Method., Results: Qualitative analyses revealed 9 themes across 2 domains related to psychiatric boarding care: in-hospital improvements and transitions of care. The follow-up survey identified 6 improvement opportunities rated as both feasible and important. Additionally, 6 psychosocial interventions, 2 delivery modalities, and 5 outcomes were rated as both feasible and important., Conclusions: Stakeholders concerned with the psychiatric boarding of youth identified numerous opportunities for improving the boarding process within 2 domains of in-hospital improvements and transitions of care. Most of the improvements were considered feasible and important with several serving as particularly viable strategies. These have the potential for implementation to improve the care of this vulnerable population and inform local and national quality improvement efforts., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Patients with severe health anxiety have complex interpersonal relationships with medical providers and others in their social context, often resulting in conflictual interactions with providers and perception of poor medical care. An adequate understanding of the causes and consequences of these interactions is lacking, particularly 1 informed by the experience of the patient. This study used qualitative methods to explore the development and maintenance of health anxiety from the perspective of patients with lived experience of coping with health anxiety and their interactions with the healthcare system., Method: We conducted qualitative interviews with 11 primary care patients purposely sampled to describe their experience living with health anxiety, provider interactions, and social and family interactions surrounding health and health anxiety. We extracted themes related to living with health anxiety and interactions with providers and other significant relationships., Results: Thematic content analysis revealed 5 themes including 3 causal themes, 1 response theme, and 1 theme reflecting factors that mitigate health anxiety. Causal themes included subthemes reflecting predisposing factors of the self, key stimulus events from patient learning history, and maladaptive social interaction factors. The response theme was comprised of 2 subthemes: logical conclusions and health anxiety symptoms. The mitigating factors theme included subthemes of a trusting care relationship and recognition of disconfirming evidence., Conclusion: The themes and constituent subthemes identified in this study largely map onto cognitive-behavioral theory of health anxiety, demonstrating alignment between patient experience and theory. The resulting model also identifies potential points of intervention in the developmental and maintenance process. We provide recommendations to maximize those points of intervention., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Following initial evaluation and management, youth requiring inpatient psychiatric care often experience boarding, defined as being held in the emergency department or another location while awaiting inpatient care. Although mental health boarding is common, little research has examined the quality of healthcare delivery during the boarding period., Objective: This study aimed to explore the perspectives and experiences of multidisciplinary clinicians and parents regarding mental health boarding and to develop a conceptual model to inform quality improvement efforts., Design, Setting, & Participants: We conducted semistructured interviews with clinicians and parents of youth experiencing boarding. Interviews focused on experiences of care and perceived opportunities for improvement were continued until thematic saturation was reached. Interviews were recorded, transcribed, and analyzed to identify emergent themes using a general inductive approach. Axial coding was used to inform conceptual framework development., Results: Interviews were conducted with 19 clinicians and 11 parents. Building on the Donabedian structure-process-outcome model of quality evaluation, emergent domains, and associated themes included: (1) infrastructure for healthcare delivery, including clinician training, healthcare team composition, and the physical environment; (2) processes of healthcare delivery, including clinician roles and responsibilities, goals of care, communication with families, policies/procedures, and logistics of inter-facility transfer; and (3) measurable outcomes, including patient safety, family experience, mental health status, timeliness of care, and clinician moral distress., Conclusion: This qualitative study summarizes clinician and family perspectives about care for youth experiencing boarding. The conceptual model resulting from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable population., (© 2022 Society of Hospital Medicine.)

Health anxiety is a chronic mental health condition that exerts substantial personal and economic burdens on patients, providers, and the larger healthcare system. Patients with health anxiety experience persistent worry and dread over the possibility that they are presently ill with an undetected or poorly defined physical illness or may soon become ill despite an absence of evidence and physician reassurance of wellness. A complication of health anxiety is that the sufferer frequently denies the presence of excessive anxiety, typically attributing their distress to an inability of the medical team to correctly identify the feared illness. As a result, these patients are challenging to engage in evidence-based psychosocial interventions. The present study protocol describes a psychosocial intervention based on cognitive-behavioral therapy that is adapted for delivery by Medical Assistants in the primary care setting. The rationale for this approach is that delivery by Medical Assistants has the potential to overcome barriers to engagement that prevent effective care. Moreover, deploying a task-shifted intervention relieves strain on the care team by sharing the responsibility for helping the patient manage health anxiety. The aim of this study is to demonstrate the effectiveness of this intervention and approach on health anxiety, while simultaneously collecting data on the barriers and facilitators of implementation, consistent with a hybrid type 1 study design. We will compare patient-level outcomes for participants randomized to the study intervention versus routine referral to mental health services and characterize the potential for implementation using qualitative data drawn from patient and clinical stakeholders., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Contamination-based obsessive-compulsive disorder (OCD) is thought to develop and be maintained by excessive propensity to experience disgust, particularly in response to perceived contaminants, and dysfunctional threat appraisals pertaining to illness. The present studies attempted to integrate these lines of research by testing the degree to which contamination-based OCD is associated with individual differences in disgust propensity and sensitivity, affective distress in response to perceived contaminants, and perceived threat of illness. In Study 1, a convenience sample of 185 adults completed self-report scales assessing obsessive-compulsive symptoms, disgust propensity and sensitivity, germ aversion, and perceived infectability. Multivariate regression showed that disgust propensity and germ aversion were the only significant predictors of contamination-based obsessions and compulsions. Exploratory analyses suggested that there was a significant indirect effect of disgust propensity on contamination-based obsessions and compulsions via germ aversion. Findings from Study 1 were replicated using a sample of twenty-six obsessive-compulsive participants. Despite the substantially smaller sample, the proportion of the total effects attributable to the mediating effect of germ aversion was comparable, consistent with a significant partial mediation in both samples. These results together suggest that contamination-based OCD symptoms are likely maintained and motivated by basic affective processes., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: To determine the antidepressant mechanism of action for repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC) in healthy women. Our primary hypothesis was that a single session of left DLPFC rTMS, compared with a session of right DLPFC rTMS, would result in better (reduced) negative nonaffective switch costs in healthy women., Background: The antidepressant mechanism of action for rTMS is not clear. It is possible that rTMS to the DLPFC improves emotion regulation, which could be a part of its antidepressant mechanism., Methods: Twenty-five healthy women were randomized to receive left high-frequency (HF) rTMS versus right HF rTMS in one session and then contralateral stimulation during a second session. Emotion regulation was assessed via switch costs for reappraisal of negatively valenced information on an affective flexibility task., Results: For negative nonaffective switch costs, the interaction effect in the two-way ANOVA was not significant (F1,19=3.053, P=0.097). Given that left HF rTMS is the approved treatment for depression, post hoc t tests were completed with particular interest in the left-side findings. These tests confirmed that negative nonaffective switch costs significantly improved immediately after left rTMS (t1,19=2.664, P=0.015) but not right rTMS., Conclusions: These findings suggest that left DLPFC HF rTMS may lead to antidepressant effects by improving the regulation of emotion.

Objective: Empirical examinations of the relation between posttraumatic stress disorder (PTSD) and objective measures of symptom over-reporting may be useful for identification of mechanisms of this previously observed relation. The present study examined the moderating effect of alexithymia, defined as a deficit in the ability to identify and describe emotions, on the relation between PTSD and over-reporting., Method: Seventy-five veterans diagnosed with PTSD were recruited from an outpatient Veterans Affairs facility and the community. Participants were administered the Miller Forensic Assessment of Symptoms Test, along with the Toronto Alexithymia Scale and PTSD Checklist within a larger study of behavioral and physiological correlates of PTSD., Results: Hierarchical linear regression analyses showed a significant moderating effect of alexithymia, such that the relation between PTSD symptom severity and over-reporting was only significant in the presence of elevated alexithymia. Evaluation of the subscales of the Toronto Alexithymia Scale showed that the effect was greatest for the Difficulty Describing Emotions subscale., Conclusions: Alexithymia should be considered as a potential mechanism contributing to the over-reporting phenomena observed in the assessment and treatment of PTSD, and warrants further study. Brief interventions to improve understanding and description of emotional experiences may help to improve accuracy of symptom report. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Physiological assessment of posttraumatic stress disorder (PTSD) presents an additional avenue for evaluating the severity of PTSD symptoms. We investigated whether the presence of a high number of uncommon symptoms attenuated the relation between self-reported PTSD symptoms and heart rate variability (HRV). Participants were 115 veterans from Operation Iraqi Freedom and Operation Enduring Freedom with or without PTSD. Symptom over-report was assessed using the Miller Forensic Assessment of Symptoms Test (M-FAST). Participants completed the Clinician-Administered PTSD Scale and M-FAST and underwent physiological assessment to determine HRV. These data were then entered into a hierarchical linear regression equation to test the moderating effect of over-reporting on the relation between PTSD symptom severity and HRV. The result of this analysis failed to demonstrate a significant moderating effect of over-reporting on the PTSD and HRV relation. HRV was a significant predictor of PTSD symptom severity, and this relation did not differ across levels of over-reporting. These findings did not support the hypothesis that over-reporting would attenuate the relation between PTSD and HRV. Clinical and research implications and directions for future investigation are discussed.

Background and Objectives: Health anxiety is characterized by a preoccupation with the possibility of having a serious health condition or disease. Contemporary conceptualizations of health anxiety have improved in recent years to incorporate a fear of acquiring an illness; however, there is limited experimental data demonstrating the presence of fear of contamination among health anxious individuals., Method: The present study utilized behavior approach tasks (BATs) to examine the degree to which contamination fear is present in elevated health anxiety. Participants were 60 undergraduate students who reported elevated health anxiety, contamination fear, or no anxiety about either health or contamination. Participants completed four BATS from which avoidance, anxiety, and disgust ratings were derived., Results: Health anxious and contamination fearful individuals exhibited a similar degree of avoidance during the BATs. Contamination fearful participants reported significantly more anxiety and disgust relative to the non-anxious controls, but not the health anxious participants. Health anxious participants did not report more anxiety or disgust than the non-anxious participants., Limitations: The use of an analogue sample may limit the extension of these findings to clinical populations. Additionally, the role of general negative affect could not be reliably determined in the absence of an anxious control group., Conclusions: These findings suggest that contamination fear may be a source of conceptual overlap between health anxiety and other disorders characterized by contamination fear. This highlights the importance of considering contamination fear in excessive health anxiety., (Published by Elsevier Ltd.)

Current models of health anxiety suggest that fear resulting from false alarms to perceived threats to one's health results in the development of hypochondriasis and related disorders. Disgust has been proposed as an affective response that may function as an etiological and maintenance mechanism in health anxiety. Moreover, the way in which an individual perceives the disgust response (disgust sensitivity) may affect health anxiety, separately from their likelihood of experiencing disgust (disgust propensity). The present study utilized multiple hierarchical regression analysis to investigate the degree to which self-reported disgust sensitivity and disgust propensity differentially predict elevated health anxiety in a sample of 620 non-treatment-seeking undergraduates. Further, this effect is tested in comparison to that of anxiety sensitivity, a construct demonstrated to be strongly related to health anxiety. Analyses indicate that disgust sensitivity, rather than disgust propensity, is primarily responsible for this relation. An additional analysis tested the specificity of disgust sensitivity relative to anxiety sensitivity. Disgust sensitivity was no longer significant after including anxiety sensitivity in the model. Suggestions for further evaluation of this relation are provided. These results suggest that although disgust sensitivity may appear related to health anxiety, this relation may be confounded by anxiety sensitivity.

A large body of evidence suggests an important role of disgust in contamination fear (CF). A separate line of research implicates various cognitive mechanisms in contamination fear, including obsessive beliefs, memory biases, and delayed attentional disengagement from threat. This study is an initial attempt to integrate these two lines of research and examines whether disgust and delayed attention disengagement from threat explain unique or overlapping processes within CF. Non-clinical undergraduate students (N = 108) completed a spatial cueing task, which provided measures of delayed disengagement from frightening and disgusting cues, and a self-report measure of disgust propensity (DP). Participants also completed a chain of contagion task, in which they provided contamination appraisals of an object as a function of degrees of removal from an initial contaminant. Results demonstrated that DP predicted greater initial contamination appraisals, but a sharper decline in estimations across further degrees of removal from the contaminant. Delayed disengagement from disgust cues uniquely predicted sustained elevations in contamination estimations across further degrees of removal from the contaminant. These results suggest that DP and delayed disengagement from disgust cues explain unique and complimentary processes in contamination appraisals, which suggests the utility of incorporating the disparate affective and cognitive lines of research on CF., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

A large body of evidence suggests that disgust is an important affective process underlying contamination fear. An independent line of research demonstrates that obsessive beliefs, particularly overestimations of threat, are also an important cognitive process underlying contamination fear. The present study attempts to integrate these two lines of research by testing whether obsessive beliefs potentiate the influence of disgust propensity on contamination fear. The interaction between disgust propensity and obsessive beliefs was tested in two large non-clinical samples (N = 252 in Study 1; N = 308 in Study 2) using two different self-report measures of contamination fear. Regression analyses supported the hypotheses in both samples. The interaction remained significant when controlling for negative affect. The results are hypothesized to suggest that contamination fear results, at least partly, from obsessive beliefs about the contamination-based appraisals that accompany heightened disgust responding. These results complement previous affective-driven explanations of the role of disgust in contamination fear by suggesting cognitive factors that similarly potentiate disgust's role in contamination fear.

Obsessive-compulsive disorder (OCD) is characterized by the presence of unwanted, intrusive thoughts coupled with ritualized behaviors intended to reduce subjective anxiety. Although once considered a homogeneous disorder, recent findings support a view of OCD as consisting of symptom subtypes. Additionally, there has been increased interest in the contribution of disgust to various forms of psychopathology. The present article summarizes the available literature on contamination-based OCD with an emphasis on the role of disgust as it pertains to the etiology and maintenance of this form of OCD. We propose an updated model of contamination-based OCD that accounts for the elevated disgust response observed in individuals with this form of OCD. Treatment implications of a disgust-based model of the disorder are discussed in the context of cognitive-behavioral therapy.

Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.

Over 8,000 adolescents and young adults (4,111 males; 4,085 females) reported on several HIV-related risk behaviors during enrollment into 10 service demonstration projects targeted to youth living with, or at risk for, HIV. Distinct risk patterns emerged by gender when predicting HIV serostatus (versus unknown serostatus/negative serostatus). Males who had injection drug risk histories, had sex with an HIV positive partner, had sexually transmitted diseases, had sex with males, and/or were homeless had an inflated risk of being HIV positive. Females who engaged in sex with an HIV partner, had sex with an injection drug user, and/or had sexually transmitted diseases, were at the highest HIV risk. For both samples, engaging in sex with women reduced the likelihood of HIV positive status. Very basic information about risk factors obtained at service intake offers important information about HIV status of "high risk" youth presenting for care in community programs, as well as suggests clear risk factors for targeted preventive efforts.

This paper uses confirmatory structural equation models to develop and test a theoretical model for understanding the service utilization history of 4679 youth who received services from 10 national HIV/AIDS demonstration models of youth-appropriate and youth-attractive services funded by the Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration. Although the projects differ from one another in the areas of emphasis in their service models, each is targeted to youth at high risk for HIV, or those youth who have already contracted HIV. Collectively, the projects represent a comprehensive adolescent HIV service model. This paper examines the characteristics of the services provided to young people ranging from outreach to intensive participation in medical treatment. Major typologies of service utilization are derived empirically through exploratory factor and cluster analysis methods. Confirmatory structural equation modeling methods are used to refine the exploratory results using a derivation and replication strategy and methods of statistical estimation appropriate for non-normally distributed service utilization indicators. The model hypothesizes that youth enter the service system through a general construct of connectedness to a comprehensive service model and through service-specific methods, primarily of outreach or emergency services. Estimates are made of the degree to which a comprehensive service model drives the services as opposed to specific service entry points.

This article describes data from 4,111 males and 4,085 females participating in 10 HIV/AIDS service demonstration projects. The sample was diverse in age, gender, ethnicity, HIV status, and risk for HIV transmission. Logistic regression was used to determine the attributes that best predict substance abuse. Males who were younger; HIV positive; homeless; involved in the criminal justice system; had a sexually transmitted disease (STD); engaged in survival sex; and participated in risky sex with men, women, and drug injectors were most likely to have a substance abuse history. For females, the same predictors were significant, with the exception of having an STD. Odds ratios as high as 6 to 1 were associated with the predictors. Information about sexual and other risk factors also was highly predictive of substance abuse issues among youth.

The acceptability of lateral interocclusal records by the Hanau H-2 articulator was studied on 28 edentulous patients. Acceptability was determined in both right and left lateral jaw movements. Of the 56 lateral interocclusal records made, 39 (70%) were accepted by the Hanau model H-2 articulator.

The following conclusions were made concerning the effects of carbon fiber orientation on the flexural fatigue resistance and bending properties of two denture base acrylic resins. Hi-I resin, regardless of fiber presence or orientation, was more resistant to flexural fatigue than Lucitone resin. Carbon fibers placed perpendicular to the direction of applied stress produced the most favorable combination of increased resistance to bending and to flexural fatigue. Production of properly oriented fibers that are well centered within the resin is technically difficult and yields less predictable property improvements than result from randomly dispersed fibers.

Fifty-seven members from ten families in which one parent and at least one child have asthma were studied with dilutional skin tests and RAST to grass pollens after determination of HLA haplotypes. We found no direct evidence for linkage of a hypothetical asthma locus with HLA or for a significant association of asthma with HLA haplotypes. Linkage between the HLA loci and a gene or genes which allow for the expression of clinical asthma could neither be proven nor disproven due to the small sample size. All of the asthmatic children had positive dilutional skin tests and RAST, suggesting that atopic asthma may be genetically controlled by the HLA chromosome (chromosome 6). Nonetheless, determination of the histocompatibility antigens can increase the value of predictive risk analysis for asthma. Such a determination may be important in the early identification of a child born to a family with atopic asthma.

Thirteen randomly selected outpatient asthmatics were treated with nebulized atropine sulfate, isoproterenol and the combination of these drugs in a randomized double-blind trial. Sequential pulmonary function parameters, cardiovascular changes and side effects were monitored over a 60-minute period following drug administration. Both atropine and isoproterenol produced significant and equivalent improvement in mean forced expiratory flow rates; the combination of drugs produced significantly greater improvement at each time interval without producing significant cardiovascular changes or side effects. Four patients failed to show clinically significant increases in expiratory flow rates following isoproterenol alone; two of these four improved following atropine alone, while two improved only when given the combination of drugs. The addition of an anti-cholinergic agent may provide a more precise assessment of reversibility of obstructive airways disease in the individual patient.