Search

An online survey was conducted of 225 occupational therapy (OT) practitioners living in the rural states of North Dakota and Wyoming to explore practice patterns and the influence of the college experience on employment choice. Findings showed that rural practitioners had greater variability of hours spent working (5.5 more hours per week, p=.028), and one more work location on average (p=.006). Therapists in urban settings spent 15% more time in fieldwork education than their rural counterparts (p=.021). Rural practice choice was influenced by participation in Level I and Level II fieldwork (p=.002) but not by loan debt. Study implications for academic programs include focusing on multiple areas of practice in the curriculum design, and exposure of students to rural practitioners and rural practice examples/experiences. Recommendations were made for rural fieldwork educator training and employer support of rural fieldwork education. Further study of the experience of working within a rural practice context as a student and OT practitioner are recommended, including variables impacting rural practitioner work with fieldwork students, and student interest in rural fieldwork placement.

Author(s): Moyer, C. Leigh; Johnson, Sean; Klug, Marilyn G.; Burd, Larry | Abstract: Introduction: The objective was to determine if pregnant women visiting the emergency department (ED) are tested for substance use as frequently as non-pregnant women. Methods: We captured all ED visits over a six-year period (2010-2016) from a single community hospital and identified women of childbearing age, defined for our study as 11-50 years old. We collected demographic data including age in years, ethnicity, body mass index, marital status, disposition, last encounter department, method of arrival, and day of week. An independent binary variable was created based on whether the woman was tested for alcohol or drugs (amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, opioids) during her visit. We then compared rates of testing for substance use by pregnancy status. Results: We identified 61,222 ED visits by women of childbearing age (range 11-50, mean 30.5, standard deviation 9.6) over a six-year period from 2010-2016. Of the 57,360 non-pregnant women, 4.14% were tested compared to 1.04% of the 3,862 pregnant women tested with a relative risk of 0.25 (pl0.001, 95% confidence interval [CI] [0.183-0.341]). The most highly tested chief complaints for all women – psychiatric or substance use concerns – showed pregnant women were still 37% and 54% less likely to be tested, respectively (risk ratio [RR] 0.46, 95% CI [0.19-1.13]; RR 0.63, 95% CI [0.41-0.96]). Beyond pregnancy status, we found no significant interaction between patient demographics and substance use testing. Conclusion: Pregnant women presenting to the ED were 75% less likely to be tested for drug or alcohol use than non-pregnant women. Our study showed only pregnancy status as a statistically significant variable in drug- and alcohol-screening rates when pregnant and non-pregnant patient chief complaints and demographics were compared. Increased attention to the screening of pregnant women for substance use may be necessary to provide adequate care and intervention to this population.

A systematic review of published literature to estimate prevalence of comorbid mental disorders in fetal alcohol spectrum disorders (FASDs) and compare with general population prevalence estimates.A PubMed search was used to locate articles reporting on FASD and mental disorders published through June 2015. Next, lists of published studies from all issues of the National Organisation for Foetal Alcohol Syndrome-UK publication Fetal Alcohol Forum-were searched. Weighted average prevalence was estimated for the comorbid mental disorders with sufficient data for analysis. We then compared prevalence of mental disorders in the FASD population with rates in the mental health literature.We identified 26 articles reporting 5984 cases of FASD. Of the 15 comorbid mental disorders, 11 had sufficient data for inclusion in the analysis. Attention-deficit/hyperactivity disorder occurred in 50% of persons with FASD (10 times the expected rate). Intellectual disability occurred at 23 times the expected rate. In 5 of the 12 disorders, rates in the FASD population significantly exceeded expected rates by 10% to 45%.Increased rates of mental disorders in people with FASD are commonly reported. Mental health providers should routinely consider FASD in the diagnosis and management of mental illness and developmental disorders. The quality of the research and precision of comorbidity estimates would be improved by additional studies including people with FASD and non-FASD comparison subjects. Until these studies are available, this review provides the best available estimates of comorbid mental disorders in people with FASD.

Date Presented 04/06/19 A survey of 225 OT practitioners living in rural states explored practice patterns and influences on employment choice. Rural and urban practitioner differences were noted in variability of hours spent working, number of work locations, and time spent in fieldwork education. Rural practice choice was influenced by fieldwork participation but not loan debt. Findings support the value of rural exposure in the curriculum and customized rural fieldwork educator support. Primary Author and Speaker: Debra Hanson Additional Authors and Speakers: Janet Jedlicka, Marilyn Klug, Nicole Harris

Context/Purpose: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients. Methods: Cross-sectional retrospective analyses on 2003-2005 Medicare hospital inpatient data from 5 states were conducted to compare predictors of in-hospital AMI mortality between rural hospital transferred and nontransferred patients. A total of 9,690 rural hospital AMI patients were identified: 3,087 were transferred to receiving hospitals and 6,603 were not transferred. Separate logistic regressions were conducted for transferred and nontransferred patient cohorts and results were compared. Results: Transfer patients were younger, more likely male, had fewer comorbidities/complications, and were less likely to expire (5.3% vs 16.7%) in the hospital. Congestive heart failure and cardiac dysrhythmia were the most common comorbidities/complications among transfer and no-transfer AMI patients, but shock (OR = 9.44) and acute renal failure (OR = 3.67) had the strongest associations with in-hospital mortality for both cohorts. Undergoing a percutaneous coronary intervention (PCI) was associated with a 42% reduction in hospital mortality risk for transfer patients. Conclusions: Transfer was associated with a greater likelihood of in-hospital AMI survival, largely but not fully explained by transfer patients being younger with fewer comorbidities/complications who are receiving advanced cardiac care. Additional studies are needed to clarify other factors that explain higher in-hospital mortality among nontransfers, such as patients’ health care decision-making.

We examined the rates of comorbid pervasive developmental disorders in participants with Tourette syndrome. We used 7288 participants from the Tourette Syndrome International Database Consortium Registry. We found 334 (4.6%; 1 of every 22 participants) with Tourette syndrome had a comorbid pervasive developmental disorder. In participants with Tourette syndrome and comorbid pervasive developmental disorders, 98.8% had one or more comorbidities (pervasive developmental disorder was not counted) compared to 13.2% in the group of participants with Tourette syndrome only. Variables from logistic modeling that were significant predictors of Tourette syndrome and pervasive developmental disorders were: male gender; no family history of tics/Tourette syndrome; and an increased number of comorbidities (P < .001). We found rates of comorbid Tourette syndrome and pervasive developmental disorders to be increased by 13 times. Identification of differences between subgroups of patients with Tourette syndrome may increase understanding of syndromal susceptibility, severity, and outcome.

Objective. Review of the prevalence of congenital heart defects (CHD) and fetal alcohol spectrum disorder (FASD). Design. We conducted a search of the Medline and Pubmed databases to identify papers reporting the association. We then searched the reference lists of the papers and reference books for additional sources. Results. We found 29 studies that met our inclusion criteria. In the 12 case series studies of subjects with FASD, the proportion of cases with a CHD (atrial [ASD] and ventricular [VSD] septal defects, other defects, or unspecified CHD) ranged from 33% to 100%. From the 14 retrospective studies, the rate of septal defects was 21%, other structural defects 6% and unspecified defects was 12%. For the 2 case–control studies, the odds of CHD ranged from 1.0 (subjects with fetal alcohol effect) to 18.0 (subjects with fetal alcohol syndrome). In the 1 prospective study of CHD the OR for a child to have CHD and FASD was 1.0. Key Conclusion. Pediatric cardiologists may have frequent contact with children with FASD and increased levels of attention to prenatal alcohol exposure as a potential etiology of CHD is indicated.

Aim: Environmental risk factors for chronic lymphocytic leukemia (CLL) have not been consistently identified. An etiologic role for ionizing radiation in CLL is controversial. Because most of the ionizing radiation to which individuals are exposed comes from radon at home, we examined CLL incidence rates in relation to residential radon levels. Methods: We used population-based rates for CLL for US states from 2007 to 2011 and measurements of residential radon made by the US Environmental Protection Agency. Results: Incidence rates for CLL were significantly correlated with residential radon levels among whites (both genders together and each gender separately; p < 0.005) and among blacks (p < 0.05). Conclusion: We speculate that radon increases CLL risk and that the mechanisms may be similar to those by which radon causes lung cancer.

Smoking is a common problem among children with learning and behavior disorders, many of whom have multiple developmental disabilities. We present data from a feasibility study to educate children about cost, disability, and loss of life from smoking. Pre- and post-test comparisons were used to examine changes. The 466 participants were from six schools. The age range was 11–18 years of age. Of the 466 students ages 11 – 18 years of age 90% were able to answer four factual questions using the calculator on the post test. We found that 66% of the students demonstrated improvement in at least one area. When asked to compare the Short Story of Life (SSL) to any other programs the student may have seen, in or out of school, 71% preferred the SSL compared to any other program they had seen. The cost per child for the SSL program was $2.89. The SSL program was found to be easy to use and inexpensive to implement in community settings.

Objective: Tourette syndrome (TS) is a common developmental disorder with childhood onset. This study utilizes the TIC consortium data to develop models of variables associated with increased severity of tics in people with TS. The TIC database comprised 5,500 people with TS. Method: This study included the 5,450 participants with clinician reported severity of tics (mild, moderate, or severe). We developed 3 models of tic severity. Results: Model 1 comprised age of diagnosis and total number of comorbidities and correctly classified 71% of mild–moderate cases, 46% of severe, and 68% of the total group. Model 2 comprised 7 of 21 comorbid conditions and classified 78% of mild–moderate cases, 53% of severe cases, and 74% of the total population. Model 3 comprised 6 comorbid conditions and correctly classified 75% of mild–moderate cases, 57% of severe cases, and 72% of the total cohort. We found the attention-deficit hyperactivity disorder was not associated with tic severity but obsessive compulsive disorder was an important variable associated with tic severity. Conclusion: This large dataset provides 3 models of variables associated with increased tic severity at the time of diagnosis. Further research is needed to identify factors associated with longitudinal changes in tic severity. This should include factors that are associated with both increased and decreased severity.

Context There is a need for models of health care that provide accessible, culturally appropriate, quality services to the population of Hispanic migrant farmworkers at risk for or diagnosed with diabetes. Purposes The purposes of this study were to describe the Migrant Health Service, Inc (MHSI), Diabetes Program, the conceptual model on which it is based, and 4 types of outcomes achieved over a 3-year period. Methods Types and amounts of medical services and education were studied. Qualitative data obtained from program records and documents were analyzed to determine the nature of the program. Quantitative data were used to measure outcomes of the program. Findings The multiplecomponent MHSI Diabetes Program is addressing economic, cultural, and language barriers experienced by the target population. The program provides a continuum of health services and education that meet American Diabetes Association (ADA) Clinical Practice Recommendations on diabetes. The program exposes regional health care professionals and university students from numerous academic disciplines to Hispanic farmworker culture. Conclusions Evidence-based program management, patient care, and program evaluation are traits of this program, which offers accessible, culturally appropriate, quality health services and education to Hispanic farmworkers. The multicomponent program model has high potential for positively impacting the health of the target population.

We compared the rate of all-cause mortality in siblings of children diagnosed with fetal alcohol syndrome (FAS) with the siblings of matched controls. The siblings of children with FAS had increased mortality (11.4%) compared with matched controls (2.0%), a 530% increase in mortality. The age of death in case siblings deaths occurred later (between 1 day and 7 years) compared with the controls (1 day to 4 years) [odds ratio (OR)=2.4 (0.4-15.6)]. Siblings of children with FAS had increased risk of death due to infectious illness [OR=13.7 (1.2-361)] and sudden infant death syndrome compared with controls [OR=10.2 (1.2-75.1)]. A diagnosis of FAS is an important risk marker for mortality in the siblings of the proband even if they do not have FAS. Maternal alcoholism appears to be a useful risk marker for increased mortality risk in diagnosed cases and their siblings. This has important implications in the management of family members of children with FAS.

Prenatal alcohol exposure can result in fetal alcohol syndrome (FAS), which may increase the risk of confinement in the corrections system. In the United States each state and four major cities' corrections systems were asked to complete a questionnaire on the prevalence of FAS and alcohol-related neurodevelopmental disorder (ARND) in the offender population, the availability of screening and diagnostic services to identify offenders with FAS and staff training needs related to FAS. The total population in the 54 entities was 3,080,904 inmates. Completed questionnaires were obtained from 42 entities (78%). The mean rate of reported substance abuse in offenders was 60.1%. Specialized programs for persons with mental retardation were reported for 44.4% of corrections facilities and 25.9% of community corrections facilities. Programs for pregnant women were reported for 46.3% of corrections facilities and 29.6% of community facilities. One program (1.9%) reported having a screening program for FAS in the corrections system. Only four programs (7.4%) reported having access to diagnostic services for FAS in the corrections facilities. Of the 3,080,904 offenders, only one offender was reported to have a diagnosis of FAS. Reported staff training needs were very large. In conclusion, corrections systems have high unmet needs to screen, identify, and treat offenders with FAS and ARND. Staff training needs are substantial.

The prevalence and magnitude of effect of individual risk markers for specific developmental disorders vary widely across diagnostic category. The four study cohorts for this project were patients from four diagnostic registries in North Dakota for fetal alcohol syndrome (FAS), autism, sudden infant death syndrome (SIDS), and Tourette syndrome. These four cohorts were used to estimate prevalence and magnitude of effect of parental risk markers in patients with developmental disabilities. Cases with North Dakota birth certificates were matched with controls. Using birth certificate data, we then examined five parental risk markers for each cohort and estimated direct and indirect effects for each risk marker by cohort. The authors found two significant paternal risk markers (age in SIDS and education in FAS). Significant maternal markers were age in SIDS, education in FAS, autism, and SIDS. Marital status was a significant risk marker in FAS. Effect sizes were estimated using paired t tests, odds ratios, and population attributable risk (PAR) for both direct and indirect effects for each marker. We estimated both direct and indirect effects to allow for direct comparisons of the differential effect estimates of each of these markers. The direct effect of parental markers differs across diagnostic cohorts of patients. Use of cohorts from similar denominator populations obtained from prevalence studies is a useful methodological tool for estimating the prevalence and magnitude of effect of risk markers.

Introduction: Prenatal alcohol exposure is an important cause of growth impairment. In this study we examined the stability of the growth measurements, including height, weight, and body mass index (BMI) percentiles, from birth to age at the time of diagnosis for subjects who were referred for evaluation to determine if they had fetal alcohol syndrome. Methods: We utilized subjects from the North Dakota Fetal Alcohol Syndrome Registry. Each person referred for assessment was provided a standardized assessment completed by a medical geneticist. We also examined differences in the diagnostic schema from the Institute of Medicine. The population consisted of 315 subjects with paired weight measurements, 234 subjects with paired height measurements, and 322 subjects with current BMI measurements. Results: Increases in weight percentiles and decreases in height percentiles were found. Children with FAS had consistently lower growth measurements. There was significant movement in and out of lower 5th and 10th percentiles by partial and no FAS children from birth to diagnosis. Discussion: The requirement for growth impairment needs to be broad rather than narrow, if most subjects with a diagnosis of FAS and partial FAS/ARND are to be captured.

The objective of this study was to use population-based data to estimate the prevalence and cost of treatment for attention-deficit hyperactivity disorder (ADHD). The North Dakota Department of Health Claims Database was used to estimate the administrative prevalence, annual cost of care per case, and total annual cost of care for subjects with ADHD compared with controls. The case population was 7745, and the mean prevalence rate was 3.9%, with a peak prevalence at 10 years of age. For children with ADHD, the annual cost of care was 649 dollars compared with that of controls at 495 dollars. Cost of care attributable to ADHD was 649 dollars - 495 dollars = 54 dollars (31%). Utilization by children with ADHD with publicly funded payers was increased 25 to 175% over that of children with privately funded coverage. In North Dakota, the annual cost of care for children with ADHD was 5.1 million dollars, 5.6% of all health care costs for children. The annual attributable cost of care was 1.79 million dollars. Thus, 1.9% of total health expenditures for children was attributable to ADHD. In the United States, the cost of care attributable to children with ADHD would be 2.15 billion dollars annually.

We conducted a 12-year prospective study of children with pervasive developmental disorders from North Dakota. In a prospective longitudinal follow-up study, of 59 patients, we found 52 patients with pervasive developmental disorders (88%). Ten (17%) declined to participate. We collected data on 42 (71%) of the original cohort. Of the 42 subjects, 1 died (1.7%). The other 41 were followed up for 492 person-years. Severity scores for the Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) declined 20% and for DSM-IV 23%. Global Assessment of Functioning improved 19%, and the average number of comorbidities decreased 45%. Thirty-seven percent of patients improved in all four measures, whereas only 5% improved in only one measure. Pervasive developmental disorders are developmental disorders with a long-term course of limited improvement for most patients. Male subjects demonstrated substantially more variability in improvement but, overall, demonstrated more improvement than female subjects. (J Child Neurol 2002; 17:681-688).

North Dakota's state-funded Dementia Care Services Program provides individualized assistance to caregivers of persons with dementia. Caregivers can contact program representatives at any time and may continue to contact them throughout the years they are caring for the person with dementia. During the program's first forty-two months of operation (January 2010 to June 2013), care consultants assisted 1,750 caregivers, primarily family members, of 951 persons with dementia. In survey responses and other self-reported data, the unpaid caregivers credited the assistance program with helping them feel more empowered, consider their charges less likely to be placed in long-term care, and use less potentially avoidable medical services such as hospitalizations and 911 calls. The program's estimated potential savings were $39.2 million from delayed long-term care placement and $0.8 million from reduced use of medical services, and its two-year costs were $1.2 million. The program's success with its rural service population, for which travel tends to be difficult and resources limited, provides a model for others to adapt. It also encourages further research on impacts of individualized support programs on persons with dementia and their caregivers.

The goal of this study was to collect prospective longitudinal information on the development of an epidemiologically defined cohort of patients with Tourette syndrome. These data may improve prognostic understanding of the condition. This information will also be important for specification of an adult phenotype for genetic marker studies. A prospective longitudinal cohort study was conducted. Fifty-four of 73 patients from our 1986 prevalence study of Tourette syndrome in North Dakota school-aged children were eligible for inclusion. The subjects were diagnosed in 1984 and 1985. We were able to interview 39 of 54 eligible patients for 507 person-years of follow-up. For the cohort, tic severity declined by 59%, global assessment of functioning improved by 50%, and the average number of comorbidities decreased by 42%. Forty-four percent of patients were essentially symptom free at follow-up. Only 22% were on medication as adults. Tourette syndrome is a developmental neuropsychiatric disorder with a long-term course that is favorable for most patients. Males demonstrated substantially more variability in improvement but overall demonstrated more improvement than females. (J Child Neurol 2001;16:431-437).

Educators’ attitudes towards distance education are known to be influenced by many factors. This study incorporated survey data that measured business educators’ attitudes toward distance education at both the baccalaureate and masters levels of instruction. Two simultaneous equations models were developed that described the relationship between the respondents’ attitudes and other factors relevant to their receptivity and support of distance education. Key influential factors were found to be the experience of the respondent and their perception of difficulties with and appropriateness of distance education. Key differences between the models were based on the teaching role and age of the respondent.

UNLABELLED Alcohol is the most common identifiable teratogenic cause of mental retardation in North America. Fetal Alcohol Syndrome (FAS) is a major public health problem, which is frequently under diagnosed by physicians. OBJECTIVE To identify and quantify the maternal risk factors and neonatal characteristics of children with FAS. DESIGN A retrospective case-control study using birth certificate data of North Dakota children diagnosed with FAS. Five controls were selected for each patient. Controls were selected from the computerized birth registry and matched by gender, year and month of birth. SUBJECTS AND SETTING A list of all the children diagnosed with FAS from the North Dakota FAS Registry was sent to the State Health Department. We were able to locate the birth certificates for 132 (56%) of the 228 cases on the registry. RESULTS Of the 132 FAS cases, 106 (80.3%) were Native Americans and 24 (18.2%) were Caucasians. In this sample 51 (38.6%) of the cases were male and 81 (61.4%) were female. Statistically significant maternal characteristics at p < 0.01 were: older mother's age, lower education level, fewer months of prenatal care, fewer prenatal visits, lower gestational age at time of delivery and less prenatal weight gain. Significant neonatal differences at p < 0.01 were lower birth weight and Apgar scores and higher incidence of congenital malformations. CONCLUSION FAS is a completely preventable developmental disability. Consumption of alcohol during pregnancy can result in lifelong physical and mental impairments on the fetus. All pregnant women should be screened for alcohol use during prenatal visits. Women with positive screens or at high risk should be identified early by the primary care physician and referred for treatment and counseling.

In a previous study, the present authors reported on the prevalence of psychoactive (psychotropic and anticonvulsant) medication use among people with intellectual disability residing in community settings in the state of North Dakota, USA. The present study replicates the earlier survey. A questionnaire was sent to all group homes serving people with developmental disabilities. Questionnaires were obtained for 100% of North Dakota group home residents. Psychoactive medications (anticonvulsants included) were used by 38% of the 1384 residents represented. The results are discussed in relation to the previous study from North Dakota.

A series of longitudinal and cross sectional studies, collected as part of the Seattle Study, were reanalyzed. A longitudinal sequential analysis (N = 232), wherein subjects were measured every seven years for four time periods, was completed on the Primary Mental Abilities test. Cohort differences were at least as strong as age differences; cohorts were generally relatively stable over the measured periods, showing little cognitive decline. A cross-sectional sequential analysis (N = 2813) was completed for the same time periods; decline with age was more evident than with the longitudinal sequential analysis. A cross-sectional analysis for the fourth time period (N = 611) showed the most marked decline of all. Interpretation of outcome was highly dependent on the analysis used.

Objective: Estimating cost savings based on limited health care events within a short time span for a dementia care program. Method: Data on health care utilization of persons with dementia (PWDs) and caregivers were gathered in the Dementia Care Services Program in North Dakota from January 2010 to January 2012. Data were aggregated into 3-month intervals and compared to 3 months before program intervention. Paired and cross-time models were used to estimate cost savings. Results: Health care cost savings for PWDs were estimated at US$143,118 to US$180,102 during the first 3 months after intervention, then decreased over time. Only the first 9 months could be used in the paired model due to small N and low power. Discussion: For programs with short time spans and limited health care events, a cross-time model can be used to estimate cost savings while producing results similar to paired models.

For caregivers of persons with dementia, estimating when that person should be placed in long-term care is difficult. Health care providers also find it hard to give an exact time as to when the person should be placed. Using data from 197 caregivers working with the Dementia Care Services Project in North Dakota, we show that asking the caregiver about their inclination to place can be equated to asking them for a specific time to place (κ = .616). Using the probability density function of time to place we were able to translate it into inclination. This inclination is easier information for the caregiver to provide and places fewer burdens on the caregiver and patient. It also provides the health care provider with a measure of time to help advise caregivers and recommend interventions and provide service organizations with measures of cost savings to support the impact of outreach and intervention.

CONTEXT/PURPOSE: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients.Cross-sectional retrospective analyses on 2003-2005 Medicare hospital inpatient data from 5 states were conducted to compare predictors of in-hospital AMI mortality between rural hospital transferred and nontransferred patients. A total of 9,690 rural hospital AMI patients were identified: 3,087 were transferred to receiving hospitals and 6,603 were not transferred. Separate logistic regressions were conducted for transferred and nontransferred patient cohorts and results were compared.Transfer patients were younger, more likely male, had fewer comorbidities/complications, and were less likely to expire (5.3% vs 16.7%) in the hospital. Congestive heart failure and cardiac dysrhythmia were the most common comorbidities/complications among transfer and no-transfer AMI patients, but shock (OR = 9.44) and acute renal failure (OR = 3.67) had the strongest associations with in-hospital mortality for both cohorts. Undergoing a percutaneous coronary intervention (PCI) was associated with a 42% reduction in hospital mortality risk for transfer patients.Transfer was associated with a greater likelihood of in-hospital AMI survival, largely but not fully explained by transfer patients being younger with fewer comorbidities/complications who are receiving advanced cardiac care. Additional studies are needed to clarify other factors that explain higher in-hospital mortality among nontransfers, such as patients' health care decision-making.

Fetal alcohol syndrome (FAS) is an important cause of mental retardation and developmental disabilities. A population based screening tool would allow for early diagnosis and entry into intervention programs. The aim of the study was to develop a brief screening tool for use in population-based settings to improve the identification of children with FAS. The FAS Screen was developed and tested in six sites. These were sites that served children and all were located in North Dakota. Screening was completed on 1013 children, 65 were found to have a positive screening score and were referred for further investigation. Forty were seen for evaluation by a medical geneticist and six were diagnosed with FAS. The estimated values for the screening tool were: specificity 94.1%, sensitivity 100%, positive predictive value 9.1% and negative predictive value 100%. The cost of screening was $13.00 per child and the cost per case identified was $4,100. The FAS Screen is a brief screening test with acceptable performance characteristics and is cost effective.

Hospital re-admissions for patients with congestive heart failure (CHF) are relatively common and costly occurrences within the US health infrastructure, including the Veterans Affairs (VA) healthcare system. Little is known about CHF re-admissions among rural veteran patients, including the effects of socio-demographics and follow-up outpatient visits on these re-admissions.To examine socio-demographics of US veterans with CHF who had 30 day potentially preventable re-admissions and compare the effect of 30 day VA post-discharge service use on these re-admissions for rural- and urban-dwelling veterans.The 2005-2007 VA data were analyzed to examine patient characteristics and hospital admissions for 36 566 veterans with CHF. The CHF patients who were and were not re-admitted to a VA hospital within 30 days of discharge were identified. Logistic regression was used to examine and compare the effect of VA post-acute service use on re-admissions between rural- and urban-dwelling veterans.Re-admitted veterans tended to be older (p=.002), had disability status (p=.024) and had longer hospital stays (p.001). Veterans Affairs follow-up visits were negatively associated with re-admissions for both rural and urban veterans with CHF (ORs 0.16-0.76). Rural veterans aged 65 years and older who had VA emergency room visits following discharge were at high risk for re-admission (OR=2.66).Post-acute follow-up care is an important factor for promoting recovery and good health among hospitalized veterans with CHF, regardless of their rural or urban residence. Older, rural veterans with CHF are in need of special attention for VA discharge planning and follow up with primary care providers.

Fetal alcohol spectrum disorders (FASD) are a common cause of developmental disability, birth defects, and mortality. The performance characteristics of current diagnostic tools for FASD are not adequately reported. This study examines the performance characteristics of the Fetal Alcohol Syndrome Diagnostic Checklist (FASDC). In a population of 658 subjects from North Dakota, we used the FASDC score to examine the agreement between FASDC score, clinical diagnosis, and the Institute of Medicine criteria for FASD. All subjects were seen for evaluation in the genetic/dysmorphology clinics, which are funded by the state to provide genetic diagnostic services for residents of North Dakota. We compared the clinical diagnosis and the FASDC scores to determine the performance characteristics of the FASDC in the categorical diagnosis of fetal alcohol spectrum (FAS), other-FASD, and a group with No-FASD. Comparisons were made using univariate and logistic models of outcomes using both the presence and the absence of alcohol exposure or FASDC phenotype data. The FASDC performance characteristics for differentiation of the FAS group from non-FASD were excellent (accuracy 99%, sensitivity 99%, and specificity 99%). Logistic models for subjects with scores in the FASD range were differentiated with an accuracy of 82%, sensitivity 85%, and specificity 80% using the data on phenotype and exposure. We were able to delineate subjects with scores in the No-FASD range with an accuracy of 78%, sensitivity 64%, and specificity 81% without including the exposure and phenotype data by use of the other descriptive data (maternal characteristics, birth records, and demographic data) from the FASDC. All diagnostic tools should have performance characteristics assessed and available before adoption for use in clinical settings. The FASDC scores produce diagnostic groupings that approximate expert clinical judgment. The tool may be useful in other clinical settings for the diagnosis of FASD or as an FASD registry or research database.

BACKGROUND: Our objective was to estimate the mortality rate in subjects with fetal alcohol spectrum disorders (FASD) and their siblings whose FASD status was unknown. METHODS: We used the state FASD Registry to link subjects with FASD to a North Dakota birth certificate. We were able to link 304 of 486 cases (63%). We used the birth certificates to identify the mother and children born to the mother (siblings). We then searched for death certificates for both the FASD cases and their siblings. We then calculated the annual and age-adjusted mortality rates for the siblings of the Registry cases and compared them with mortality rates from North Dakota. RESULTS: The FASD case mortality rate was 2.4%, with a 4.5% mortality rate for their sibings, accounting for 14% of all deaths when compared to the North Dakota residents matched by age and year of death. The sibling deaths accounted for 21.5% of all cause mortality matched by age and year of death. The age-standardized mortality ratios were 4.9 for the FASD cases and 2.6 for their siblings whose FASD status was unknown. CONCLUSIONS: Mortality rates for FASD cases and their siblings were increased and represent a substantial proportion of all cause mortality in North Dakota. Prevention of FASD may be a useful strategy to decrease mortality. Birth Defects Research (Part A), 2008. © 2008 Wiley-Liss, Inc.

Aims: To present an incremental process for a staged screening strategy to identify women at increased risk of having a child with fetal alcohol spectrum disorder (FASD) and to enhance the management of women using alcohol during pregnancy. We include an illustrative example of the development of a screening component using an existing data set. Methods: We describe a seven-step protocol to screen for alcohol use during pregnancy. The screening process begins with a one-question initial screen, followed by exposure assessment, maternal risk stratification to estimate risk for FASD, and concludes with recommendations for intervention and monitoring of exposure for women drinking during pregnancy. Conclusions: This screening process has very modest time commitments in the early stages. Time commitments increase for women drinking during pregnancy and the process focuses on the population at highest risk of having a child with FASD. The process has the benefit of risk specificity, since the process refines risk estimates for an adverse outcome specific for FASD. The process concludes with a programme to facilitate intervention and to monitor changes in prenatal alcohol exposure during pregnancy. Prevention of FASD is an important public health priority. In addition to the ongoing study of clinical strategies to improve detection rates of alcohol exposure at all stages of pregnancy, additional research on the tools and the process used in screening efforts is urgently needed. The efforts should also include research on both the screening tools and the outcome of the screening process in routine prenatal care settings.

Objective: To complete a community based efficacy study of a SIDS risk reduction methodology. Methods: We utilized two community sites for this study: 1) a Native American home visiting program for pregnant and young mothers; and 2) an obstetrics department in a community hospital. Pre and posttests were used to measure learning. The risk reduction intervention was delivered by hospital nurses or the home visiting staff and required about 20 minutes. Each of the nine risk factors was discussed. Results: We completed paired pre and post testing with 341 women. The pre tests found substantial knowledge deficits about SIDS risk factors in both groups. The pre and posttest changes for the nine risk factors ranged from 5% to 74%. Participants from both groups demonstrated nearly equivalent rates of learning for all nine of the risk concepts. Conclusion: This study demonstrated the efficacy of this brief intervention program. The program was effective in increasing parental knowledge of the risk factors targeted by this study in both settings. The magnitude of change supports additional research with this program in other settings and with additional populations.

Background Tourette Syndrome (TS) is a neurodevelopmental disorder of childhood. Learning disabilities are frequently comorbid with TS. Using the largest sample of TS patients ever reported, we sought to identify differences between subjects with TS only and subjects with TS and a comorbid learning disability. Methods We used the Tourette Syndrome International Consortium database (TIC) to compare subjects with comorbid Tourette Syndrome and learning disabilities (TS + LD) to subjects who did not have a comorbid learning disability (TS - LD). The TIC database contained 5,500 subjects. We had usable data on 5,450 subjects. Results We found 1,235 subjects with TS + LD. Significant differences between the TS + LD group and the TS - LD group were found for gender (.001), age onset (.030), age first seen (.001), age at diagnosis (.001), prenatal problems (.001), sibling or other family member with tics (.024), two or more affected family members (.009), and severe tics (.046). We used logistic modeling to identify the optimal prediction model of group membership. This resulted in a five variable model with the epidemiologic performance characteristics of accuracy 65.2% (model correctly classified 4,406 of 5,450 subjects), sensitivity 66.1%, and specificity 62.2%. Conclusion Subjects with TS have high prevalence rates of comorbid learning disabilities. We identified phenotype differences between the TS - LD group compared to TS + LD group. In the evaluation of subjects with TS, the presence of a learning disability should always be a consideration. ADHD may be an important comorbid condition in the diagnosis of LD or may also be a potential confounder. Further research on etiology, course and response to intervention for subjects with TS only and TS with learning disabilities is needed.

Fetal alcohol syndrome (FAS) is a common cause of neuropsychiatric disorders, growth impairment and craniofacial abnormalities. The syndrome may be more common than has been previously reported. Considerable controversy exists over the approaches for diagnosis of the syndrome. Method : In this study, we examined the rate of agreement for two diagnostic schema using 385 subjects that had been referred for assessment of possible FAS. Cases had initially been diagnosed using the Fetal Alcohol Syndrome Diagnostic Checklist (FASDC). We then reviewed the chart of each of the 385 subjects referred and assigned each subject to a category from the Institute of Medicine (IOM) Criteria or to a NOFAS category. We then compared the IOM categories with the FASDC. Results: Rates of agreement with the IOM Criteria ranged from 59–71% using the FASDC. Poorest agreement was found in conjunction with partial FAS (PFAS)/alcohol-related neurodevelopmental disorder (ARND). Removal of exposure data from the scores greatly affected accuracy for the FASDC scores. Discussion : The schema had only modest rates of agreement for classification of subjects with a diagnosis of FAS. This study does not determine if the diagnosis used in the development of the cohort was accurate. Further study utilizing multiple diagnostic schema in a single population will help examine the rates of diagnostic agreement between differing diagnostic schema. A valuable cohort to study would be the subjects in the CDC surveillance system. A perspective study utilizing a single cohort and applying multiple diagnostic criteria at the same time would be useful.

Fetal alcohol syndrome (FAS) is a common developmental disorder with impairments in multiple neuropsychiatric spheres of varying severity. Few population-derived studies of the behavioral phenotype are available. The purpose of this study was to estimate the prevalence of neuropsychiatric disorders in three groups: subjects who met criteria for FAS (n=152); subjects who met criteria for partial FAS/ARND (n=150); and referred subjects who did not meet criteria for either FAS or partial FAS/ARND (n=86). Each subject had a standardized evaluation by a medical geneticist. All subjects were from North Dakota. We found increases in the prevalence rates of neuropsychiatric disorders in subjects with FAS compared to subjects with partial FAS/ARND and the lowest rates in the group that did not meet criteria for either FAS or partial FAS/ARND. Comorbid attention deficit hyperactivity disorder occurred in 73% of cases with FAS, in 72% cases with partial FAS/ARND, and in 36% subjects who did not meet criteria for either. For other neuropsychiatric disorders, a similar distribution of comorbidity was found. This study supports the concept of a continuum of impairment resulting from prenatal alcohol exposure. The presence of complex cognitive, behavioral, and physical symptomatology in the affected subjects with prenatal alcohol exposure would seem to fit well under the diagnostic rubric of fetal alcohol spectrum disorder (FASD). Diagnosis and long-term management will require increasing access to multidisciplinary child development teams including mental health professionals who treat children and adolescents. Adults will require care primarily from teams with expertise in mental health and developmental disabilities.

Alcohol exposure during pregnancy is a well-recognized public health problem. Accurate assessment of prenatal alcohol exposure is especially important to identify women in need of intervention. In this study, a 36-item prenatal questionnaire was utilized to survey a representative sample of prenatal care providers to examine prevalence rates of exposure. The questionnaire included three common screening tools for alcohol use during pregnancy and the items necessary to establish a maternal risk profile. In North Dakota, 1081 pregnant women were included in the sample. Eighty (7.4%) were Native American and 952 (88%) were White. The TWEAK screening tool was positive for 253 (23.4%) of the women. Native American women had a 71% increase in positive TWEAK screenings compared to White women. Logistic regression was used to develop a high-risk model. The data from prenatal care can also be used for maternal risk stratification. Early identification can provide opportunity for early interventions to decrease total exposure during pregnancy and to improve the outcome for the child.

Fetal alcohol syndrome (FAS) is a common cause of birth defects and neuropsychiatric impairment. Identification of affected people is crucial for early entry into intervention programs and for the development of prevalence estimates. The objective of this project was to determine if screening for FAS in a community elementary school-based setting was feasible, to estimate prevalence in the screened population, and to determine if a screening program for FAS can be implemented using available personnel from the community. The FAS Screen was used to screen kindergarten students enrolled in a school system. Students with scores on the FAS Screen above the cutoff for a positive screen (20) were referred to one of several diagnostic clinics for evaluation. Over a 9-year period, 1384 students were screened and 69 (5%) had a positive screen (20 or above). These 69 children were then seen in a genetics/dysmorphology diagnostic clinic and 7 (10%) were found to have FAS (n=6) or partial FAS (n=1). The prevalence of affected children (FAS and partial FAS) was 1 per 198 students or 4.3 per 1000. The FAS Screen was completed annually by school staff, teachers, social workers, and psychologists. The test has acceptable epidemiologic performance characteristics in a community setting. The screening takes about 8-10 min. The procedure was well accepted in the community. This screening strategy was inexpensive to implement (less than US8.00 dollars per student), and can be easily included with the other screens completed at kindergarten entry.

Fetal alcohol syndrome (FAS) is a common developmental disability. FAS is thought to be 100% preventable. While this is a theoretical truth, a prevention rate of 100% appears unlikely in the near future. However, several prevention strategies are available. In this paper, we examine the potential cost savings from prevention of one case of FAS each year in the state of North Dakota. We utilized the North Dakota Health Claims Database to examine annual cost of health care for children birth through 21 years of age with FAS and controls. The mean annual cost of health care for children birth through 21 years of age with FAS was US2842 dollars (n=45). This is US2342 dollars per capita more than the annual average cost of care for children in North Dakota who do not have FAS (US$500 per year). Prevention of one case of FAS per year in North Dakota would result in a cost savings of US128,810 dollars in 10 years and US491,820 dollars after 20 years. After 10 years of prevention, the annual savings in health care costs alone for one case of FAS would be US23,420 dollars.

The objective of this study was to use population-based data to estimate the cost and phenotypic variation of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). The North Dakota Department of Health's Claims Database was used to estimate the administrative prevalence, rates of comorbidity, and cost of care for subjects with ADHD. The case population was 7745 children. We then examined the 10 most frequent comorbidities for a defined condition in the International Classification of Diseases-9th edition ( ICD-9). The observed prevalence of general health conditions was 12 to 70% less than expected. The presence of a comorbid condition resulted in increases in costs of care of $381 to $731 per case per year. The observed prevalence of comorbid mental health conditions was 97 to 5286% higher than expected. The prevalence of conditions comorbid with ADHD varies widely, with rates of general medical conditions decreased and rates of most mental disorders increased. The costs for comorbidity with general health conditions were offset by large decreases in prevalence rates compared with controls. We identified an ADHD paradox: decreased rates of comorbid general health conditions and increased rates of comorbid mental disorders. Further research on comorbidity in ADHD is required. ( J Child Neurol 2003; 18:653-660).

Objective Our objective was to assess the effectiveness of skin care protocols, including a body wash and skin protectant, on skin breakdown in 2 nursing homes. Design This was a quasi-experimental pretest/posttest design study. Setting and subjects Adult residents (n = 136) of 2 skilled nursing homes consented to participate in this study. Seventy percent were women; the sample average age of 82 years. Instruments A researcher-designed data recording form documented resident demographics, incidence and type of skin breakdown or pressure ulcer, presence of urinary or fecal incontinence, and assessment of the effectiveness of body wash and skin protectant. Methods Baseline data on prevalence of pressure ulcers and skin protocol were collected weekly for a 3-month period followed by a week-long educational program by the researchers about skin care and the body wash and skin protectant. During the 3-month trial with the body wash and skin protectant incorporated into routine care, research assistants recorded resident data weekly and researchers again assessed prevalence and incidence of pressure ulcers and skin breakdown weekly. Results Incorporation of a body wash and skin protectant into a skin care prevention and early intervention protocol in 2 nursing homes documented a decrease in skin breakdowns from 68 pre-intervention to 40 postintervention; the decrease in agency B was statistically significant. There was a statistically significant decrease in stage I and II pressure ulcer incidence overall (pre-intervention = 19.9%, postintervention = 8.1%). Nurses evaluated the body wash and skin protectant as effective for 98% of the time used. Conclusion Implementation of a protocol for skin care along with staff education, including the prophylactic use of a body wash and skin protectant, reduced the incidence of skin breakdown, including pressure ulcers and perineal dermatitis, in 2 long-term care facilities.

Background: Studies evaluating the relationship between smoking and cancer spread are limited. Methods: We studied the relationship between cancer stage at diagnosis (local, regional, or metastatic) and smoking history (current, previous, or nonsmoker). For lung cancer, patterns of spread were also studied. Results: In a tumor registry for eastern North Dakota, northwestern Minnesota, and northern South Dakota, 11,716 cases were identified from 1986 to 2001. Current smokers (relative risk [RR], 2.11; 95% confidence interval, 1.93 to 2.32; P < .001) and previous smokers (RR, 1.56; 95% confidence interval, 1.42 to 1.72; P < .001) had an increased risk of metastatic disease at diagnosis. Current smokers (RR, 1.39; 95% confidence interval, 1.29 to 1.51; P < .001), but not previous smokers, also had an increased risk of regional disease. An increase in metastatic disease was most evident for prostate cancer (RR, 1.53; P = .003). An increase in regional disease was most evident for head and neck (RR, 3.53; P < .001), prostate (RR, 1.83; P = .030), and breast cancer (RR, 1.22; P = .005). Compared with previous smokers, current smokers with metastatic lung cancer were more likely to have involvement of the brain (33.6% v 23.0%; P = .004), bone marrow, adrenal gland, and pericardium (24.7% v 15.9%; P = .004). Conclusion: Previous or current smoking is a risk factor for increased cancer stage in a wide range of malignancies. Further study is required to determine whether this association is causal.

Research on neuropsychiatric disorders has produced a number of very important findings in the last few decades. However, several problems continue to hinder research in this area. One problem area has been the appropriate classification of disease status for probands and extended family members in linkage studies. In this article, we examine rates of misclassification in a 12-year follow-up study of children previously diagnosed with Tourette syndrome. At the 12-year follow-up, we found a 5 to 12% rate of misclassification of previously diagnosed cases. We present a model of a linkage study with three classification steps. The model demonstrates that an error rate of 5% would result in misclassification of 20% of true cases by step three. Adding additional steps to improve diagnostic accuracy may increase rather than decrease classification error. (J Child Neurol 2001;16:499-504).

The objective of this study was to compare rates of infant sleeping position and other risk factors for sudden infant death syndrome from 1991 before the “Back to Sleep” campaign to rates in 1998 after the campaign. We used a cross-sectional risk factor prevalence study of risk factors for the years 1991 and 1998. In North Dakota the prevalence rates of prone sleeping declined 72% for American Indian infants and 62% for Caucasian infants. We were unable to identify a corresponding decline in SIDS in North Dakota for this time period. The relationship between sleeping position and SIDS may be more complex in rural and frontier settings and in American Indian populations than in urban and majority populations. The generalizability of this study is limited by the rural setting and small sample size. Longer term surveillance and additional reports from sites with pre “Back to Sleep” data as a baseline for both SIDS rates and sleeping position will be important to clarify the rate of prone sleeping position and SIDS.

Aim : To identify pre- and perinatal risk factors for autism. Method: Case control study. We matched names of patients from North Dakota who met DSM criteria for autism, a pervasive developmental disorder, and autistic disorder with their birth certificates. Five matched controls were selected for each case. Results: Univariate analysis of the 78 cases and 390 controls identified seven risk factors. Logistic modeling to control for confounding produced a five variable model. The model parameters were X 2 = 36.6 and p < 0.001. The five variables in the model were decreased birth weight, low maternal education, later start of prenatal care, and having a previous termination of pregnancy. Increasing father's age was associated with increased risk of autism. Conclusion: This methodology may provide an inexpensive method for clinics and public health providers to identify risk factors and to identify maternal characteristics of patients with mental illness and developmental disorders.

Aims: To identify pre- and perinatal risk factors for Tourette disorder. Methods: Case control study. We matched names of patients who met DSM criteria for Tourette disorder with their birth certificates. For each case five controls were selected. The controls were matched by sex, year and month of birth. Results: Univariate analysis of the 92 cases and the 460 matched controls identified 4 risk factors; one categorical variable- trimester prenatal care begun and 3 continuous variables - apgar score at 5 minutes, month prenatal began and number of prenatal visits. Logistic modeling to control for confounding produced a three variahle model (apgar score at 5 minutes (OR = 1.31), number of prenatal visits (OR = .904) and fathers age (OR = .909). The model parameters were; X 2 = 19.76; df = 3; p

A retrospective case control study utilizing birth certificate data in a population of children with Fetal Alcohol Syndrome (FAS) or Fetal Alcohol Effect (FAE) and controls in North Dakota was completed. Using the North Dakota FAS registry, 97 cases of FAS and FAE aged birth-18 years of age were identified. The North Dakota Department of Vital Records then searched for the child's birth certificates. For each case child, four controls were selected from the birth records. The controls were of the same race, sex, month and county of birth as the cases. Birth certificates for 68 children were identified, 44 with FAS and 24 with FAE. When compared with the FAE group, the FAS group had lower birth weights and mothers who began prenatal care later in pregnancy. The FAS/FAE group combined had mothers who were older, were more likely to be unmarried, had less weight gain during pregnancy, started prenatal care later in pregnancy and had fewer prenatal visits compared to controls. The FAS/FAE children had lower birth weights and higher rates of sibling deaths. The use of birth certificate data is a useful data source to compare maternal, paternal and prenatal characteristics for a population of children with FAS/FAE.

INTRODUCTION Hospital re-admissions for patients with congestive heart failure (CHF) are relatively common and costly occurrences within the US health infrastructure, including the Veterans Affairs (VA) healthcare system. Little is known about CHF re-admissions among rural veteran patients, including the effects of socio-demographics and follow-up outpatient visits on these re-admissions. PURPOSE To examine socio-demographics of US veterans with CHF who had 30 day potentially preventable re-admissions and compare the effect of 30 day VA post-discharge service use on these re-admissions for rural- and urban-dwelling veterans. METHODS The 2005-2007 VA data were analyzed to examine patient characteristics and hospital admissions for 36 566 veterans with CHF. The CHF patients who were and were not re-admitted to a VA hospital within 30 days of discharge were identified. Logistic regression was used to examine and compare the effect of VA post-acute service use on re-admissions between rural- and urban-dwelling veterans. RESULTS Re-admitted veterans tended to be older (p=.002), had disability status (p=.024) and had longer hospital stays (p