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The goal of this study was to examine the degree to which youths and caregivers attend to different factors in evaluating their experiences with mental health programs. Youth (n = 251) receiving mental health services at community agencies and their caregivers (n = 275) were asked open-ended questions regarding the positive and negative aspects of the services. Qualitative analyses revealed some agreement but also divergence between youth and caregivers regarding the criteria by which services were evaluated and aspects of services that were valued most highly. Youths’ positive comments primarily focused on treatment outcomes while caregivers focused more on characteristics of the program and provider. Youths’ negative comments reflected dissatisfaction with the program, provider, and types of services offered while caregivers expressed dissatisfaction mainly with program characteristics. Results support the importance of assessing both youth and caregivers in attempts to understand the factors used by consumers to evaluate youth mental health services.

The treatment of Medicaid enrollees diagnosed with depression or schizophrenia was examined to determine whether adherence to treatment guideline was associated with health care financing strategy, clinical outcomes, and cost-effectiveness. Individuals in a fee-for-service condition were significantly more likely to receive treatment consistent with guidelines than those in managed care. Mental health costs were higher for individuals diagnosed with schizophrenia, individuals in an acute phase of illness at intake into the study, and those receiving treatment consistent with practice guidelines. Being in an acute phase of illness and having treatment that comported with recommended practice guidelines were associated with higher total social costs. Policy implications of the findings and recommendations for future research are discussed.

The present study assessed agreement between student self-report and teacher ratings of bullying and victimization relative to psychological, behavioral, and academic correlates. Middle school students (N=1442) and teachers completed surveys evaluating peer relationships and psychosocial adjustment. Analyses of variance and logistic regressions were used to examine rater agreement on bullying/victimization and adjustment among groups (bullies, victims, bully/victims, and uninvolved) identified by rater (student self-report only, teacher-report only, concordant reports, and controversial reports). Concordant and controversial groups had among the greatest psychosocial and academic difficulties. Student learning difficulties and moodiness interacted with teacher reports of bullying and victimization, respectively, with agreement between teacher and student self reports of bullying greater at higher levels of learning problems and agreement for victimization lower at higher levels of moodiness. The results indicate biases in rater perspective of student behavior and continue to support the need for multiple raters of student functioning.

This study examined the ability of early risk factors to predict delinquency referrals. Significant risk factors included externalizing behaviors, prenatal smoking, parent marital status, and mother's education. Students with three or more risk factors had eight times the number of delinquency referrals than those with no identified risk factors.

Purpose Use of complementary and alternative medicine (CAM) is increasing, but some dietary supplements have potentially negative side effects. This study examines CAM and dietary supplement use among a national sample of adolescents. Methods A total of 1280 adolescents 14–19 years old completed an online survey in 2002 about lifetime and past-30-day use of all CAM modalities, and specifically about use of herbal medicines and dietary supplements. We e-mailed invitations to 12,353 members of Harris Interactive's national Youth Query panel, and filled age/gender quotas sample targets. Data were then weighted to reflect the U.S. adolescent population by gender, race/ethnicity, urbanicity, region, parents' education, propensity to be online, and likelihood of nonresponse. Chi-square and logistic regression analyses were done using SPSS. Results Seventy-nine percent of adolescents had used CAM in their lifetime, 48.5% in the previous month; 46.2% had used dietary supplements in their lifetime, 29.1% in the previous month; 9.3% reported concurrent use of supplements and prescription medication in the previous month. Factors associated with CAM and supplement use included being female, positive attitudes towards CAM, and being age 16–17 years (rather than in younger or older age groups). Commonly used supplements included ginseng, zinc, echinacea, ginkgo, weight loss supplements, and creatine. Conclusions Many adolescents use CAM and dietary supplements, including a significant number concurrent with prescription medications. Commonly used supplements (weight loss supplements and creatine) are closely linked to attempts to change body shape. Health care providers should be aware of CAM and supplement use by adolescents.

To determine the calculated daily patient cost (cost minimization) of medical glaucoma therapy and review cost trends.Experimental, controlled, prospective study.The actual volume of various glaucoma medications or glaucoma medications with redesigned bottles was determined for most commercially available sizes of the tested products. The drops per milliliter based on the actual volume and the daily costs of the dosage schedules recommended by the manufacturers were compared. The cost of each bottle of medication was determined from the average wholesale price (AWP) in the United States. A comparison to 1999 prices where applicable will be analyzed to review costing trends.The generic timolol products (range, US dollars 0.38-US dollars 0.46 per day) were similar on a cost per day basis vs Betimol (Santen, Napa Valley, California, USA), Optipranolol (Bausch and Lomb Pharmaceuticals, Tampa, Florida, USA) and Timoptic (Merck, West Point, Pennsylvania, USA). Their percentage cost increase ranged from 5% to 22% since 1999, except for generic timolol XE gel-forming solution (48%). Betagan (Allergan, Irvine, California, USA), Betoptic S (Alcon Laboratories, Fort Worth, Texas, USA), and Ocupress (Novartis, Duluth, Georgia, USA) ranged from US dollars 0.88 to US dollars 1.11 per day, and their percentage cost increase ranged from 33% to 53%. Some brand-only products have raised their AWPs a greater percentage, including Betoptic S (37%), Iopidine (Alcon, Fort Worth, Texas, USA) (50%), Ocupress (Novartis Ophthalmics, Duluth, Georgia, USA) (53%), and Pilopine gel (Alcon, Fort Worth, Texas, USA) (32%). The mean cost per day for the topical carbonic anhydrase inhibitors Azopt (Alcon Laboratories; US dollars 1.33 per day) and Trusopt (Merck; US dollars 1.05 per day) differed from 1999 when prices were almost identical. Cosopt (Merck; timolol 0.5% plus dorzolamide 2%, US dollars 1.04 per day) was less than the cost of separate bottles of a topical carbonic anhydrase inhibitor and a beta-blocker. The selective alpha-2 agonist brimonidine 0.15% with Purite (Alphagan-P, Allergan, 5 ml) twice daily was US dollars 1.29 per day. The prostaglandin analogs were comparably priced with Lumigan (Allergan) US dollars 0.95 per day, Xalatan (Pharmacia and Upjohn, Kalamazoo, Michigan, USA) US dollars 1.25 per day, Travatan (Alcon Laboratories) US dollars 1.01 per day, and Rescula (Novartis) US dollars 0.90 per day.All generic timolol, Betimol, Optipranolol, Timoptic, and Timoptic XE (Merck) ranged from US dollars 0.38 to US dollars 0.50 per day. Other beta-blocker products were about twice as costly, ranging from US dollars 0.88 to US dollars 1.11 per day. Cosopt (US dollars 1.05 per day) was less costly than separate bottles of a topical beta-blocker and a topical carbonic anhydrase inhibitor dosed three times daily or twice daily. The prostaglandin analogs ranged from US dollars 0.90 per day (Rescula) to US dollars 1.25 per day (Xalatan). Newer glaucoma medications exhibit similar costs per day in many cases, compared with more traditional medications, especially with greater price increases in older brand-only products.

Two stigmatizing attitudes related to dangerousness and personal responsibility may undermine the opportunities of persons with serious mental illness. This study set out to examine path models that explain how these attitudes lead to discriminatory behavior and to assess the impact of antistigma programs on components of personal responsibility and dangerousness models. Two hundred thirteen persons were randomly assigned to one of five antistigma conditions: education on personal responsibility, education on dangerousness, contact with a person with serious mental illness where personal responsibility is discussed, contact where dangerousness is discussed, or no change. Persons completed an attribution questionnaire (AQ) representing personal responsibility and dangerousness path models at pretest, posttest, and 1-week followup. They also completed tasks that represented helping behavior. Goodness of fit indexes from linear structural modeling were mixed for both models but suggested that fear of dangerousness was a key attitude leading to discriminatory behavior. Results also showed that subjects who had contact with persons with serious mental illness experienced greater changes than subjects in the education or control groups did on measures of attribution and helping behavior.

Background This study examines sustainment of an EBI implemented in 11 United States service systems across two states, and delivered in 87 counties. The aims are to 1) determine the impact of state and county policies and contracting on EBI provision and sustainment; 2) investigate the role of public, private, and academic relationships and collaboration in long-term EBI sustainment; 3) assess organizational and provider factors that affect EBI reach/penetration, fidelity, and organizational sustainment climate; and 4) integrate findings through a collaborative process involving the investigative team, consultants, and system and community-based organization (CBO) stakeholders in order to further develop and refine a conceptual model of sustainment to guide future research and provide a resource for service systems to prepare for sustainment as the ultimate goal of the implementation process. Methods A mixed-method prospective and retrospective design will be used. Semi-structured individual and group interviews will be used to collect information regarding influences on EBI sustainment including policies, attitudes, and practices; organizational factors and external policies affecting model implementation; involvement of or collaboration with other stakeholders; and outer- and inner-contextual supports that facilitate ongoing EBI sustainment. Document review (e.g., legislation, executive orders, regulations, monitoring data, annual reports, agendas and meeting minutes) will be used to examine the roles of state, county, and local policies in EBI sustainment. Quantitative measures will be collected via administrative data and web surveys to assess EBI reach/penetration, staff turnover, EBI model fidelity, organizational culture and climate, work attitudes, implementation leadership, sustainment climate, attitudes toward EBIs, program sustainment, and level of institutionalization. Hierarchical linear modeling will be used for quantitative analyses. Qualitative analyses will be tailored to each of the qualitative methods (e.g., document review, interviews). Qualitative and quantitative approaches will be integrated through an inclusive process that values stakeholder perspectives. Discussion The study of sustainment is critical to capitalizing on and benefiting from the time and fiscal investments in EBI implementation. Sustainment is also critical to realizing broad public health impact of EBI implementation. The present study takes a comprehensive mixed-method approach to understanding sustainment and refining a conceptual model of sustainment. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0183-z) contains supplementary material, which is available to authorized users.

The goal of this study was to examine the relationships of transformational leadership and organizational climate with working alliance, in a children's mental health service system. Using multilevel structural equation modeling, the effect of leadership on working alliance was mediated by organizational climate. These results suggest that supervisors may be able to impact quality of care through improving workplace climate. Organizational factors should be considered in efforts to improve public sector services. Understanding these issues is important for program leaders, mental health service providers, and consumers because they can affect both the way services are delivered and ultimately, clinical outcomes.

Policymakers shape implementation and sustainment of evidence-based practices (EBPs), whether they are developing or responding to legislation and policies or negotiating public sector resource constraints. As part of a large mixed-method study, we conducted qualitative interviews with 24 policymakers involved in delivery of the same EBP in two U.S. states. We analyzed transcripts via open and focused coding techniques to identify the commonality, diversity, and complexity of implementation challenges; approaches to overcoming those challenges; and the importance of system-level contextual factors in ensuring successful implementation. Key findings centered on building support and leadership for EBPs; funding and contractual strategies; partnering with stakeholders; tackling challenges via proactive planning and problem solving; and the political, legal, and systemic pressures affecting EBP longevity. The policymaker perspectives offer guidance on nurturing system and organizational practice environments to achieve positive outcomes and for optimally addressing macro-level influences that bear upon the instantiation of EBPs in public sector child welfare systems.

This study examined the effects of familiarity with and social distance from persons who have serious mental illness on stigmatizing attitudes about mental illness.A total of 208 community college students completed three written measures about familiarity, perception of dangerousness, fear, and social distance. Path analysis with manifest-variable structural modeling techniques was used to test a version of a model in which familiarity influences the perception of dangerousness, which in turn influences fear, which influences social distance from persons with serious mental illness.Most of the participants reported experience with mental illness. Scores on the three written measures largely supported the path model. Correlations between the perception of dangerousness and fear as well as between fear and social distance were particularly strong.Approaches to social change that increase the public's familiarity with serious mental illness will decrease stigma. Further studies are warranted that focus on how contact between members of the general public and persons who have serious mental illness may be facilitated.

Leptin, a product of both adipose tissue and the placental syncytiotrophoblast and a potential regulator of primate conceptus development, increases in the maternal circulation with advancing gestation. This increase may be potentiated by estrogens, which also increase as pregnancy progresses. In the present study adipose tissue was collected from nonpregnant (n = 5) baboons (Papio sp) and in baboons during early (days 58-62; n = 5), mid (days 98--102; n = 5), and late (days 158-162; n = 5) pregnancy (term, approximately 184 days). Additionally, placental estrogen production was inhibited in pregnant baboons by the removal of fetal androgen precursors via fetectomy at midgestation, with tissues collected from fetectomized (n = 5) baboons approximately 60 days later. Leptin, estrogens, and androgens were quantitated in maternal serum by RIA. Leptin (LEP) and leptin receptor (LEP-R(L) and LEP-R(S) isoforms) messenger ribonucleic acids (mRNAs) were quantitated by competitive RT-PCR, and leptin concentrations were determined by RIA in maternal adipose and placental villous tissues. Although LEP transcript abundance in adipose tissues was unchanged as a result of pregnancy or with advancing gestation, the leptin protein level was higher (P < 0.02) in pregnant baboons in early gestation than in nonpregnant baboons and increased with gestational age (P < 0.04). Maternal serum estrogens (estradiol and estrone) and androgens (androstenedione and testosterone) were lower (P < 0.0001) in fetectomized baboons than in intact controls. Serum leptin concentrations were unchanged by fetectomy, but the abundance of LEP mRNA transcripts was lower (P < 0.003) in sc adipose tissue and 3-fold higher (P < 0.05) in placenta. Similarly, the leptin protein level declined (P < 0.05) in sc adipose tissue and increased (P < 0.05) in placenta in fetectomized baboons. Although LEP-R(L) mRNA levels were unchanged after fetectomy, placental LEP-R(S) transcript abundance was lower (P < 0.04) than in pregnancy-intact baboons matched for gestational age. Results suggest that both adipose tissue and the placenta may contribute to maternal hyperleptinemia during normal primate pregnancy. Furthermore, the withdrawal of placental steroids results in the enhanced placental leptin production that is commensurate with a decline in production by sc adipose tissue.

Leptin is a potential regulator of conceptus development. We have previously suggested that in primate pregnancy, leptin biosynthesis is regulated by estrogen in a tissue-specific manner. Therefore, the objective of the current study was to determine the mechanism of estrogen action on LEP promoter activation in divergent cell types. The effects of estrogen were investigated in estrogen receptor (ER)-positive MCF-7 breast cancer cells and in ER-negative JEG-3 choriocarcinoma cells. Cells were transfected with a leptin-luciferase or an estrogen responsive element (ERE)-luciferase reporter construct, in conjunction with ERalpha, ERbeta, or empty vector expression plasmids. Cells were treated with estradiol and/or the specific estrogen antagonists, ICI-182,780 or 4-hydroxytamoxifen. In MCF-7 cells, estradiol stimulated (P

Leptin is a polypeptide hormone originally thought to be produced exclusively by adipocytes. Recently, however, both leptin messenger ribonucleic acid (mRNA) and leptin protein were identified in human placental trophoblast cells, suggesting a potential role in primate pregnancy. In the present study, venous blood samples were collected at 5-day intervals during gestation from baboons (Papio sp), an established model for the study of human pregnancy, as well as from nonpregnant baboons, and leptin concentrations were determined by RIA. Additionally, placental villous tissue was collected upon cesarean delivery at early (days 60–62; n = 5), mid (days 98–102; n= 5), and late (days 159–167; n = 5) gestation (term = ∼184 days), and leptin mRNA was quantitated by competitive RT-PCR. Finally, in situ hybridization was employed to localize transcripts to specific placental cell types. Results determined that maternal leptin levels (mean ± sem), which were dramatically greater (P < 0.01) than those in nonpregnant cycling baboons (1.4 ± 0.1 ng/mL), increased (P < 0.005) with gestational age from 63.6 ± 10.4 ng/mL on day 60 of gestation to 157.8 ± 16.1 near term. Levels declined to those found in cycling baboons by 15 days postdelivery. In contrast to maternal leptin concentrations, placental leptin mRNA decreased (P < 0.02) with advancing pregnancy, as transcript abundance declined approximately 8-fold from early to late gestation. Maternal peripheral leptin concentrations were positively correlated (r = 0.66; P < 0.001) whereas placental leptin mRNA levels were negatively correlated (r= −0.64; P < 0.01) with gestational age. Expression of leptin mRNA transcripts, as evidenced by RT-PCR in villous tissue, was localized principally within syncytiotrophoblast by in situ hybridization. In summary, changes in maternal peripheral leptin concentrations and placental leptin mRNA abundance that occur commensurate with advancing gestational age may imply evolving roles for the polypeptide with advancing primate pregnancy. In this capacity, localization of leptin transcripts within the baboon syncytiotrophoblast suggests the potential for autocrine or paracrine interactions within this endocrinologically active tissue. Finally, both the similarities in leptin ontogeny in baboon and human pregnancy and the singular enhancement of maternal leptin levels inherent throughout baboon gestation emphasize the potential of this nonhuman primate model for the study of leptin action in the maternal-fetoplacental unit.

ObjectiveYouth substance use exacts costly consequences for a variety of important health outcomes. We examined and compared prevalence rates and a common set of psychosocial factors of lifetime and current substance use among child welfare-involved youths and community youths from two nationally representative data sets.MethodUsing the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health, we compared prevalence rates and conducted logistic regression models for eight binary outcome measures of substance use: lifetime and current use of alcohol, inhalant, marijuana, and other illicit drugs to examine predictors of substance involvement in the two samples.ResultsSubstance use prevalence was higher among child welfare-involved youths than community youths for lifetime marijuana use, lifetime and current inhalant use, and lifetime and current other illicit drug use. Among both child welfare-involved and community youths, delinquency was the factor most strongly associated with all lifetime substance use outcomes. Notably, family structure and parental closeness were important protective factors against current substance use among child welfare-involved youths. For community youths, poorer emotional health was the strongest indicator of current substance use.ConclusionsSubstance use among all adolescents is a critical public health concern. Given the heightened vulnerability of child welfare-involved youths, it is particularly important to focus prevention and early intervention efforts on this population. Further research should explore additional factors associated with substance use among these youths so that child welfare and behavioral health systems may jointly target prevention and intervention efforts.

Balancing fidelity and adaptation during implementation of evidence-based practices is a critical issue for healthcare organizations; however, the processes involved in adaptation are not well unde...

This chapter considers the role of experiments in regard to evaluation and action research in determining whether change in educational contexts can be attributed to the introduction of an intervention approach or programme. It explains the three classes of experimental design: 'true' experimental designs, such as randomised, controlled trials (RCTs), 'quasi-experimental' designs, and also 'small-n' experimental designs. True' and 'quasi-experiments' are 'studies of deliberate intervention. In the case of a 'true' experimental design such as an RCT, allocation to groups must be random. 'Small- n' experimental designs involve the manipulation of an independent (treatment) variable across a pre-intervention baseline phase, an intervention phase, and commonly a post-intervention phase. Most published studies of the effectiveness of school-based interventions use quasi-experimental designs. It is important for educational researchers to be aware of the beliefs and values of participants and stakeholders and indeed of underlying policy contexts and political realities.

Many efforts to implement evidence-based programs do not reach their full potential or fail due to the variety of challenges inherent in dissemination and implementation. This article describes the use of concept mapping—a mixed method strategy—to study implementation of behavioral health innovations and evidence‐based practice (EBP). The application of concept mapping to implementation research represents a practical and concise way to identify and quantify factors affecting implementation, develop conceptual models of implementation, target areas to address as part of implementation readiness and active implementation, and foster communication among stakeholders. Concept mapping is described and a case example is provided to illustrate its use in an implementation study. Implications for the use of concept mapping methods in both research and applied settings towards the dissemination and implementation of behavioral health services are discussed.

Background Adaptations are often made to evidence-based practices (EBPs) by systems, organizations, and/or service providers in the implementation process. The degree to which core elements of an EBP can be maintained while allowing for local adaptation is unclear. In addition, adaptations may also be needed at the system, policy, or organizational levels to facilitate EBP implementation and sustainment. This paper describes a study of the feasibility and acceptability of an implementation approach, the Dynamic Adaptation Process (DAP), designed to allow for EBP adaptation and system and organizational adaptations in a planned and considered, rather than ad hoc, way. The DAP involves identifying core elements and adaptable characteristics of an EBP, then supporting implementation with specific training on allowable adaptations to the model, fidelity monitoring and support, and identifying the need for and solutions to system and organizational adaptations. In addition, this study addresses a secondary concern, that of improving EBP model fidelity assessment and feedback in real-world settings. Methods This project examines the feasibility, acceptability, and utility of the DAP; tests the degree to which fidelity can be maintained using the DAP compared to implementation as usual (IAU); and examines the feasibility of using automated phone or internet-enabled, computer-based technology to assess intervention fidelity and client satisfaction. The study design incorporates mixed methods in order to describe processes and factors associated with variations in both how the DAP itself is implemented and how the DAP impacts fidelity, drift, and adaptation. The DAP model is to be examined by assigning six regions in California (USA) to either the DAP (n = 3) or IAU (n = 3) to implement an EBP to prevent child neglect. Discussion The DAP represents a data-informed, collaborative, multiple stakeholder approach to maintain intervention fidelity during the implementation of EBPs in the field by providing support for intervention, system, and organizational adaptation and intervention fidelity to meet local needs. This study is designed to address the real-world implications of EBP implementation in public sector service systems and is relevant for national, state, and local service systems and organizations.

Background: The goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States. Methods: Participants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data. Results: A total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups. Conclusions: EBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light. Background The implementation of evidence-based practices (EBPs) into real-world children’s mental health service settings is an important step in improving the quality of services and outcomes for youth and families [1,2]. This holds especially true for clients in the public sector who often have difficulty accessing services and have few alternatives if treatments are not effective. Public mental health services are embedded in local health and human service systems; therefore, input from multiple levels of stakeholders must be considered for effective major change efforts such as implementation of EBP [3,4]. In public mental healthcare, stakeholders include not only the individuals most directly involved–the consumers, clinicians, and administrative staff–but also program managers, agency directors, and local, state, and federal policymakers who may structure organizations and financing in ways more or less conducive to EBPs. Considerable resources are being used to increase the implementation of EBPs into community care; however, actual implementation requires consideration of multiple stakeholder groups and the different ways they may be impacted. Our conceptual model of EBP implementation in public sector services identifies four phases of

Few studies have investigated the prevalence of maltreatment among youths in public sectors of care despite the critical public health concern and the burden of suffering on such youths. The current study examined the prevalence of multiple types of maltreatment across five public sectors of care. Youths aged 11–18 ( n = 1,135) enrolled in one of five public sectors of care reported on their maltreatment history using the Childhood Trauma Questionnaire. Across all sectors, 78% of youth reported experiencing at least moderate levels of maltreatment with the majority (58%) reporting multiple types of maltreatment. The prevalence of maltreatment was highest for youths involved in the alcohol/drug (86%) and child welfare (85%) sectors, and lowest in the serious emotional disturbance sector (72%). Logistic regressions were conducted to examine differences in the likelihood of multiple types of maltreatment by sector affiliation, controlling for the effects of gender, race/ethnicity, and age. The results indicate that rates of maltreatment across sectors do not differ greatly from those in child welfare. The high incidence of maltreatment across all sectors, not solely child welfare, indicates that all youth in public sectors of care should be screened for a history of maltreatment when they enter into care.

The interaction between the vitreous and the internal limiting membrane of the retina is important in the pathoetiology of numerous ocular disease processes. Recent studies have focused on the vitreo-retinal interface in the context of age-related macular degeneration (AMD), linking vitreo-retinal adhesion to exudative AMD in particular. This review summarizes our knowledge of vitreous anatomy and recent investigations regarding vitreomacular adhesion and AMD.

To describe the clinical characteristics and long-term outcomes of children diagnosed over a 30-year period with acquired nonaccommodative esotropia (ANAET).Retrospective chart review of a population-based cohort.All pediatric (19 years of age) residents of Olmsted County, Minnesota, who were diagnosed with ANAET from January 1, 1965, to December 31, 1994.The medical records of all potential patients identified by the resources of the Rochester Epidemiology Project were reviewed.Incidence, clinical characteristics, and long-term motor and sensory outcomes of children with ANAET.A total of 174 children were diagnosed during the 30-year period, yielding an incidence of 1 in 287 live births. The median age at diagnosis for the 174 patients was 4.0 years (range, 10 months to 18.2 years), and 61% (107) were male (P = 0.009). Although 11% (8/75) of those queried were diplopic, none of the 174 was subsequently diagnosed with an intracranial lesion. During a mean follow-up of 10.9 years (range, 0 days to 37 years), 127 patients (73%) underwent strabismus surgery (mean, 1 surgery; range, 0-3 surgeries). Among the 127 patients who underwent surgery, the median final stereoacuity was 3000 seconds of arc, including 8 patients (6.3%) with ≥ 50 seconds of arc. Patients who were older (44 months) at ANAET diagnosis (P = 0.005) and without amblyopia at their initial examination (P0.001) were more likely to achieve excellent final stereopsis.In this population-based cohort, ANAET occurred in 1 in 287 children and was more prevalent among male children. Although diplopia was relatively common, none of the children were found to have an intracranial malignancy. Most patients achieved good motor and sensory outcomes, with the best results among those with a later onset of their deviation and no amblyopia.The author(s) have no proprietary or commercial interest in any materials discussed in this article.

When asked about substance use, youths typically endorse higher levels of use than parents, suggesting that parents are often unaware of their child's drug and alcohol use. This study sought to examine the level of concordance between reports of youths enrolled in public sectors of care and their parents, and identify potential predictors of parental awareness of substance use and related problems.Youths receiving services in one or more public sectors of care (N = 985; 67% male) and their parents were interviewed about the youths' substance use and substance use problems, as well as associated demographic, parental, and youth factors.As has been found in other studies, youths generally reported higher rates of substance use and substance use problems compared with parents. Rates of agreement ranged from κ = .24 (sedatives) to κ = .67 (marijuana) and were higher for drug problems (κ = .47) than for alcohol problems (κ = .34). Predictors of parental awareness of drug problems included youth gender (male), race (White compared with Hispanic), and higher ratings of youth's functional impairment. Predictors of parental awareness of alcohol problems included race (White compared with Hispanic), lower levels of youth-reported parental monitoring, lower levels of parental depression, and higher ratings of youth functional impairment.In this high-risk population, a significant proportion of parents are unaware of their child's alcohol (30%) and substance use (50%) problems. Services geared toward enhancing parental awareness, especially for parents of Hispanic and female youths, may increase communication and treatment seeking.

To report refractive and surgical outcomes in a cohort of children with accommodative esotropia.Retrospective population-based cohort.All pediatric patients (19 years) diagnosed with accommodative esotropia in Olmsted County, Minnesota, from January 1, 1975, to December 31, 1994.Medical records identified by the Rochester Epidemiology Project were reviewed for spectacle and surgical management.Rate of surgical intervention and discontinuation of spectacles for esotropia.A total of 306 children with accommodative esotropia were diagnosed during the study years; 244 (80%) had fully accommodative esotropia (FAET) and 62 (20%) had partially accommodative esotropia (PAET). The Kaplan-Meier rate of discontinuing spectacles for strabismus in this population was 8% by 5 years after diagnosis, 20% by 10 years, and 37% by 20 years. Children born prematurely (P = 0.046) or with a greater initial hyperopic refractive error (P0.001) were significantly less likely to become spectacle-free during the follow-up period. During a median follow-up of 9.8 years (range, 0-27.9 years), 33 (13.5%) of the 244 subjects with FAET eventually underwent strabismus surgery. Male gender (P = 0.039) and an earlier age at onset (P = 0.008) and diagnosis (P0.001) of FAET were associated with a higher likelihood of requiring surgery.The majority of children with accommodative esotropia in this population continued to require spectacle correction into their second decade of life. A small proportion of children with FAET required surgical intervention, which was more likely to occur among boys and in those with an earlier age at onset and diagnosis of their deviation.

Recognition and diagnosis of the individual forms of childhood strabismus are important for the best preservation of visual function. Esotropia is the most common form of pediatric ocular deviation in the West, whereas exotropia predominates in the East. Accommodative esotropia is the most prevalent form of strabismus in the West, comprising half of all esodeviations. Congenital, or infantile, esotropia accounts for less than 10% of all pediatric esotropia, a figure much smaller than once widely believed. Intermittent exotropia is the second most common form of childhood strabismus in the West and the most commonly diagnosed form of exodeviation worldwide. Hyperdeviations are uncommon, with fourth cranial nerve palsy being the most prevalent etiology. Major independent risk factors associated with strabismus development include: prematurity, central nervous system (CNS) impairment, low birth weight, family history, and refractive error. Recent studies have reported a decline in the number of surgeries performed for strabismus; however, population-based data of congenital esotropia in the United States confirms a more stable rate.

Moral distress has the potential to affect every practice setting in nursing; however little research has been conducted that examines the presence and impact of moral distress for nurses working in long-term care. This article reports the results of a pilot study that examined the experience and presence of moral distress of registered nurses in a long-term care setting. A convenience pilot sample of 6 nurses participated in audio-taped open-ended interviews. Interview questions were formulated using Corley's theory of moral distress as the theoretical framework. Findings indicated that nurses' experiences of moral distress were precipitated most often by disagreements with family regarding treatment decisions for residents that impacted quality of life and lack of resources to meet residents' assessed needs. Moral distress had both a positive and negative impact on nurses with nurses reporting that the presence of moral distress had little impact on the quality of care received by residents.

Over the past decade in the United States, the number of private residential facilities for youth has grown exponentially, and many are neither licensed as mental health programs by states, nor accredited by respected national accrediting organizations. The Alliance for the Safe, Therapeutic and Appropriate use of Residential Treatment (A START) is a multi-disciplinary group of mental health professionals and advocates that formed in response to rising concerns about reports from youth, families and journalists describing mistreatment in a number of the unregulated programs. This article summarizes the information gathered by A START regarding unregulated facilities. It provides an overview of common program features, marketing strategies and transportation options. It describes the range of mistreatment and abuse experienced by youth and families, including harsh discipline, inappropriate seclusion and restraint, substandard psychotherapeutic interventions, medical and nutritional neglect, rights violations and death. It reviews the licensing, regulatory and accrediting mechanisms associated with the protection of youth in residential programs, or the lack thereof. Finally, it outlines policy implications and provides recommendations for the protection of youth and families who pursue residential treatment.

Tumor necrosis factor (TNF) and lymphotoxin alpha (LT-alpha) are immunomodulators that have been hypothesized to contribute to susceptibility to type 1 diabetes (T1D). Several polymorphisms in the TNF and LT-alpha loci have been extensively studied for T1D association, with conflicting reports. In this study, we examined two TNF variants and one LT-alpha variant for T1D association in 283 Caucasian, multiplex T1D families for which complete human leukocyte antigen (HLA) genotyping data are available. Initially, association with T1D was seen for LT-alpha A1069G (intron A, p=0.011, rs909253) and TNF G(-308)A (p1x10(-5), rs1800629), but no association was observed for TNF G(-238)A (rs361525). After adjusting the data for linkage disequilibrium (LD) with DRB1-DQB1 haplotypes, however, only one polymorphism, TNF G(-238)A showed significant association with T1D (p0.006). When HLA-DR3 haplotypes were examined, the A allele of TNF G(-238)A was significantly overtransmitted to affected offspring (p0.009). Including HLA-B data in the analysis revealed that TNF (-238)A is present exclusively on DR3 haplotypes that also carry HLA-B18. Transmission proportion of B18-DR3 haplotypes did not differ between those with TNF (-238)A and those with TNF (-238)G. Thus, variation at TNF does not affect the T1D risk for B18-DR3 haplotypes, and the apparent association of TNF(-238)A with T1D may simply reflect its presence on a high-risk haplotype.

A 42-year-old woman who underwent single lung transplantation who received tacrolimus and a 58-year-old woman with pneumonia and multiple comorbidities who received haloperidol both experienced drug-induced prolongation of cardiac repolarization. The second woman also developed torsade de pointes. Critically ill patients are particularly susceptible to developing torsade de pointes due to various comorbidities, electrolyte disturbances, and receipt of numerous drugs. These two case reports illustrate the increased risk for drug-induced cardiotoxicity in the critically ill patient. They also indicate the need for current knowledge derived from basic research and retrospective case reports on drug-induced torsade de pointes to be integrated into the existing body of knowledge. Guidelines can then be developed to help prospectively reduce the frequency of adverse effects in intensive care patients. Research is necessary regarding identification of high-risk patients before drugs are administered, and clarification of the proper role of therapeutic QT monitoring in clinical practice.

We previously suggested that cadmium (Cd), an environmental toxicant and constituent of tobacco smoke, inhibits progesterone secretion in cultured human placental trophoblasts by inhibiting low-density lipoprotein receptor mRNA expression. In the current study, we investigated whether Cd also disrupts progesterone synthesis via P450 cholesterol side-chain cleavage (P450scc) and 3b-hydroxysteroid dehydrogenase (3b-HSD), enzymes that play important roles in placental steroidogenesis. Human cytotrophoblasts were purified by density gradient centrifugation and incubated in Dulbecco modified Eagle medium 1 10% fetal bovine serum with 0, 5, 10, or 20 mM CdCl2 for 96 h. Cells progressed to syncytiotrophoblastic maturity regardless of treatment. No differences (P . 0.05) in cell protein and lactate dehydrogenase activity were observed between untreated trophoblasts and those treated with CdCl2. However, P450scc and 3b-HSD mRNA transcript levels declined in a dose-dependent manner (P ,0.05) in trophoblasts cocultured with 5, 10, or 20 mM CdCl2. P450scc activity was similarly inhibited (P , 0.05) by CdCl2 treatment, although 3b-HSD activity was not significantly affected. Coculture with 8-bromo-cAMP enhanced progesterone secretion in untreated cultures but did not reverse the decline in progesterone secretion induced by CdCl2 treatment. CdCl2 failed to influence cAMP content in cultured cells. Collectively, results suggest that P450scc enzyme is another site at which Cd interferes with placental progesterone production. However, it is unlikely that an inhibition of cAMP is involved with the inhibition of progesterone biosynthesis by Cd in human trophoblasts. environment, placenta, progesterone, toxicology, trophoblast

In this study, the paths between two prejudicial attitudes (authoritarianism and benevolence) and a proxy measure of behavioral discrimination (social distance) were examined in a sample drawn from the general public. Moreover, the effects of two person variables (familiarity with mental illness and ethnicity) on prejudice were examined in the path analysis. One hundred fifty-one research participants completed measures of prejudice toward, social distance from, and familiarity with mental illness. Goodness-of-fit indexes from path analyses supported our hypotheses. Social distance is influenced by both kinds of prejudice: authoritarianism (the belief that persons with mental illness cannot care for themselves, so a paternalistic health system must do so) and benevolence (the belief that persons with mental illness are innocent and childlike). These forms of prejudice, in turn, are influenced by the believers' familiarity with mental illness and their ethnicity. We also discuss how these findings might contribute to a fuller understanding of mental illness stigma.

The baboon (Papio sp.) is an accepted nonhuman primate model for the study of the endocrinology of human pregnancy. To further characterize this model with regard to leptin function, messenger RNA transcripts for both long (Ob-RL) and short (Ob-RS) leptin receptor isoforms were identified in maternal tissues at various stages of gestation. Thus, placental villous, subcutaneous and omental adipose tissues were collected upon cesarean delivery at early (Days 60-62), mid (Days 98-102) and late (Days 159-164) pregnancy (term approximately 184 days). Additionally, amniochorion, decidua, and corpus luteum were collected in late gestation. Expression of Ob-RL and Ob-RS transcripts was determined in relation to constitutively expressed glyceraldehyde-3-phosphate dehydrogenase via reverse transcriptase-polymerase chain reaction, and transcripts were localized within specific placental cell types by in situ hybridization. Ob-RL and Ob-RS transcripts were present in amniochorion, decidua, and corpus luteum at term and appeared constitutively expressed throughout gestation in placenta and adipose tissues. Ob-RS was expressed in greater (P0.02) abundance than Ob-RL in all tissues. Within the placenta, receptor isoforms were localized predominantly to the syncytiotrophoblast. The expression of leptin receptor transcripts in maternal adipose tissues, as well as in the syncytiotrophoblast, amniochorion, decidua, and corpus luteum, suggests the potential for autocrine/paracrine roles for the polypeptide in the endocrinology of primate pregnancy. These are the first such observations in a nonhuman primate and support the use of the baboon as a model for the study of leptin in human pregnancy.

Objective Although there has been a dramatic increase in the number of evidence-based practices (EBPs) to improve child and adolescent mental health, the poor uptake of these EBPs has led to investigations of factors related to their successful dissemination and implementation. The purpose of this systematic review was to identify key findings from empirical studies examining the dissemination and implementation of EBPs for child and adolescent mental health. Method Of 14,247 citations initially identified, 73 articles drawn from 44 studies met inclusion criteria. The articles were classified by implementation phase (exploration, preparation, implementation, and sustainment) and specific implementation factors examined. These factors were divided into outer (i.e., system level) and inner (i.e., organizational level) contexts. Results Few studies used true experimental designs; most were observational. Of the many inner context factors that were examined in these studies (e.g., provider characteristics, organizational resources, leadership), fidelity monitoring and supervision had the strongest empirical evidence. Albeit the focus of fewer studies, implementation interventions focused on improving organizational climate and culture were associated with better intervention sustainment as well as child and adolescent outcomes. Outer contextual factors such as training and use of specific technologies to support intervention use were also important in facilitating the implementation process. Conclusions The further development and testing of dissemination and implementation strategies is needed to more efficiently move EBPs into usual care.

Conclusions: While many adolescents report using contraception and condoms adolescents living in households with parenting siblings are more likely to have unmet health care needs. A high proportion of all adolescents report having ever been pregnant; those with parenting siblings have their own children 2 1/2 times more often than those without parenting teen siblings. These findings suggest a need for targeted interventions addressing secondary as well as primary pregnancy prevention. (excerpt)