People with developmental disabilities are recognized as a vulnerable population and are frequently at increased risk due to their physical, social, economic and societal disparities. Despite these vulnerabilities, the regulations that govern community-based residential settings for the developmentally disabled provide little oversight with regard to home environmental health hazards such as lead, mercury, carbon monoxide, pesticides, radon and volatile organic compounds. Minimal data are available about the environmental health risks experienced by people in residential settings for the developmentally disabled and about how the behaviors and choices of support staff affect the indoor air quality in these residences. This study assessed the home characteristics, household behaviors and practices that place people with developmental disabilities at health risk from environmental hazards in their homes. Homes (N=57) run by three major service providers of residential services for the developmentally disabled in Anne Arundel County, Maryland were selected using random stratified sampling for evaluation. A survey and a home environmental assessment conducted by an observational walk-through of each home were used to assess the presence of neurotoxicants such as lead and mercury in the home, protective devices such as carbon monoxide detectors and radon testing, and the use of behaviors and practices that contribute to indoor pollution from pesticides, environmental tobacco smoke and cleaning products.;Twenty-eight homes (49%) had at least one source of carbon monoxide exposure and 21 (72%) of these homes had no carbon monoxide detector. **Carbon monoxide detectors tended to be more likely in homes with than in homes without carbon monoxide sources. Radon was a concern. Fifty-six of 57 homes were not tested for radon. In 41 of the homes basements, where carbon monoxide and radon are likely to accumulate, were used as living space for staff and developmentally disabled residents. Forty-nine homes reported professional pesticide contracts and 56 homes contained products with volatile organic compounds. Regulation and education of providers is necessary to prevent environmental health risks in this vulnerable population. More research is needed to investigate the home environmental health risks of people with developmental disabilities and their staff living in residential settings.

Addiction to heroin and other opiates is a complex, multi-faceted problem that is considered to be resistant to treatment interventions. Addicts use greater quantities of drugs more frequently than social users and are more severely impaired as shown by related social, legal, and interpersonal problems. These individuals consume a disproportionate share of available treatment resources. Traditional approaches to treatment are not effective in maintaining sobriety among chronic addicts. Available information on substance abuse has focused on the experience of men. Little is known of women's experiences as addicts and how societal responses to female addicts differ from those of men. Data on prevalence, differences in progression and consequences of addiction by gender are limited. There is a need for greater intervention into the psychological, social and community systems of the addict's drug use and behavior patterns to promote post-treatment abstinence. The purpose of this study was to identify characteristics of women who are chronic opiate addicts and to explore psychological, social, and life experiences which inhibit abstinence and adaptation to recovery. Data were collected through a series of intensive interviews with four female opiate addicts. The potential for linking understanding of addiction recovery as a psychological process which incorporates predictable phases and transitions of identity with the prevention of relapse is explored. Theories of crisis, loss and grief focus on resolution of the experience as an essential and final phase of the transformation process. Promotion of full retirement from active addiction and acceptance of a sober lifestyle may be enhanced by such a theoretical model. Implications of the study address the potential for more effective and population-specific models of assessment, intervention, and treatment retention for high-risk, hard to reach populations of chronic addicts. The key factors appear to be a sufficient length of time to accomplish this transition and a belief in the ultimate success of such an effort.

Background. Insulin-like growth factors (IGFs) have mitogenic and anti-apoptotic effects on prostate epithelial cells. Through modulation of IGF bioactivity, IGF binding proteins (IGFBPs) also have growth regulatory effects on prostate cells. Operating through the vitamin D receptor (VDR), vitamin D shows strong inhibitory effects on prostate cancer growth in both laboratory and human studies. Recent evidence indicates that vitamin D-induced prostate cancer inhibition is accompanied by increased IGFBP expression, suggesting that the vitamin D and IGF regulatory systems may operate together to affect prostate cancer. Methods. We sought to examine whether VDR gene polymorphisms affect prostate cancer risk -either independently or with plasma IGF or IGFBP levels - in a population-based case-control study in Shanghai, China. Histologically-confirmed cases of primary prostate cancer newly diagnosed between 1993 and 1995 (N = 191) and randomly selected age-matched population controls (N = 304) submitted to in-person interviews and blood draws. Genomic DNA was used to determine FokI and BsmI genotypes; IGF and IGFBP concentrations were determined from plasma. Results. No significant independent association of either the BsmI or the FokI VDR markers with prostate cancer was observed, though a small effect of BsmI cannot be ruled out owing to the low observed prevalence of its B allele. However, among men with the ff FokI genotype, those with the highest tertile of IGFBP-3 had a significantly decreased risk versus those with the lowest tertile (OR = 0.14; 95% CI = 0.04--0.56; ptrend < 0.01), while among men with the FF and Ff FokI genotypes IGFBP-3 was not associated with risk. Similarly, IGFBP-1 was significantly inversely associated with prostate cancer risk among men with the ff FokI genotype (OR = 0.25; 95% CI = 0.07--0.85; ptrend = 0.02), but not among men with the FF and Ff genotypes. No such FokI specific effects were noted for IGF-I or IGF-II. In addition, among population controls, IGF-II levels were significantly lower among those with the ff genotype versus the FF and Ff genotypes (p = 0.03), and IGFBP-1 levels appeared to increase with increasing copies of the f FokI allele. No associations between FokI genotype and levels of IGF-I of IGFBP-3 were observed. Conclusions. These findings in a low-risk population suggest that the IGF and vitamin D regulatory systems may interact to affect prostate cancer risk. Further studies are needed to confirm these findings and the clarify the underlying biological mechanisms.

Background. Black women with breast cancer are more likely to be diagnosed at a later stage compared to white women, which, in part, has been traditionally attributed to social/cultural factors. Black/white differences in the prevalence of obesity have been documented. In most studies, obesity is associated with a later stage of breast cancer at diagnosis. This study aims to assess to what extent the racial difference in stage at diagnosis can be explained by racial differences in obesity. Methods. Newly diagnosed breast cancer cases (white, N = 585; black, N = 381) were identified from hospitals in the Baltimore metropolitan area from 1991-1997. Patient information including age, race, weight, height, and pathology reports were obtained from hospital medical records. Census-based socioeconomic status (SES, including income and education) were obtained from 1990 U.S. Census files. Results. Black women were more likely than white women to be diagnosed with breast cancer at TNM stage II or greater (age-adjusted odds ration (OR) = 1.51; 95% confidence interval (CI), 1.15-1.99). Further, black women were more likely than white women to be overweight or obese (age-adjusted OR = 2.70; 95% CI, 2.01-3.61). A high body mass was significantly associated with an advanced stage of breast cancer at diagnosis (OR 1.59; 95% CI, 1.17-2.16). This association was more apparent in young women (<50 years, OR = 2.47; 95% CI, 1.43-4.28) than in older women (OR = 1.30; 95% CI, 0.90-1.90). Adjustment for the higher prevalence of obesity in black women reduced the risk of later stage of breast cancer at diagnosis in black women compared to white women by approximately 30%. Conclusions. Obesity is a risk factor for later stage of breast cancer at diagnosis, particularly in young women. The higher prevalence of obesity among young black women may play an important role in explaining their relative disadvantage in stage at diagnosis of breast cancer. Nonetheless, a racial difference in stage of breast cancer at diagnosis persists after adjustment for obesity and SES.

The Psychoeducational Intervention for Children of Trauma by Understanding through Research and Education (PICTURE) evaluated whether an art psychotherapy intervention was effective in improving short-term psychological and behavioral outcomes in elementary school children who have witnessed domestic violence. The study population consisted of 45 children, aged 5-12, from three elementary schools in Baltimore County, Maryland, who had witnessed domestic violence. Children were randomized to either an art therapy intervention followed by an arts and crafts class or an arts and crafts class followed by art therapy. Each intervention lasted for 10 sessions and met once a week for 45 to 60 minutes. Information was collected from the children on self-esteem and depression, and from their teachers on the children's behaviors. The information was collected at three time points (baseline, 10 weeks, and 20 weeks). Mixed model analyses showed that the art therapy intervention was significantly more effective than the arts and crafts class in reducing Attention Deficit-Hyperactivity Disorder risk and hyperactivity as measured by the Conners Teacher Rating Scale. There was also suggestive evidence of art therapy effectiveness in reducing depressive symptoms, teacher-rated hyperactivity and teacher-rated oppositional behavior in these elementary aged-children who had witnessed domestic violence. The study results suggest that art therapy may be a viable option toward helping children who have witnessed domestic violence with the resulting psychological symptoms and behaviors.

Schizophrenia is a severe and persistent mental illness that affects upwards of two million Americans and its treatment is estimated to cost {dollar}32 billion annually. Although pharmacotherapy represents the mainstay of treatment for schizophrenia, recent pharmacoepidemiologic data on practice patterns in large U.S. populations are limited. To address this need, a study was conducted with the following aims: (1) to characterize the patterns of pharmacologic management of schizophrenia and its demographic and clinical correlates in typical clinical practice settings; (2) to develop analytic models to examine the associations between characteristics of drug therapy and outcomes; and (3) to look for evidence of behavioral toxicity of antipsychotic medications. The data from this study were derived from a patient survey supplemented with medical record information of 719 participants recruited from inpatient and outpatient psychiatric facilities in two states for the Schizophrenia Patient Outcomes Research Team (PORT) study. The final study samples consisted of 224 inpatients and 358 outpatients that met eligibility criteria and had valid medical record data. Ethnic disparities in prescribing were identified, such that non-white patients received fewer newer antipsychotic medications, more long-acting injectable (depot) antipsychotic medications, higher average daily antipsychotic doses, and fewer adjunctive medications than their white counterparts, regardless of treatment setting. Geographic variations in prescribing patterns, in which newer antipsychotics and adjunctive medications (inpatients only) were prescribed more frequently in rural areas of State A and in urban areas of State B, and depot antipsychotics were prescribed more often in urban areas of State A and rural areas of State B, were also noted. The hypothesized model of an indirect relationship among pharmacotherapy and outcomes variables (functioning and satisfaction) that is mediated by symptoms and medication side effects was not supported by the data in either treatment setting. Also, evidence of behavioral toxicity of antipsychotics was not identified. Pronounced variations in the pharmacologic management of schizophrenia were revealed. Investigations of the outcomes of pharmacotherapy and the behavioral toxicity of antipsychotic medications should be undertaken, utilizing different measurement scales and a prospective, longitudinal study design.

Background. For women with chronic conditions, care often concentrates on the underlying disorder to the exclusion of cancer screening recommendations. This occurs in the face of lengthening life spans for those with chronic illnesses. Research objective: This study investigated the relationship between chronic illness and the receipt of breast cancer screening services, while controlling for the influence of various established predictors of screening. Data source: Survey data from the 1996 Medical Expenditure Panel Survey (MEPS) Household component. Methods: The influence of chronic illness on the likelihood of having a clinical breast exam (CBE) or mammogram was estimated using logistic regression models. Since a gold standard for measurement of chronicity did not exist, three different measures--number of chronic diseases, Charlson Comorbidity Index, and the presence of mobility and cognitive limitations---were used. Population studied: Women forty years or older (N = 4169). Principal findings: Of the chronicity measures examined, only mobility and cognitive limitations were significant. Women with either limitation were 25 to 30% less likely to be screened even though they had more ambulatory care visits than those without limitations. Neither the number of chronic conditions nor the Charlson Comorbidity Index score were significant predictors of screening. Other significant predictors of screening included age, education, income, insurance, having a usual source of care, and living in a metropolitan statistical area. Conclusions: Although women with mobility and cognitive limitations use more health care services, they are less likely to be screened for breast cancer. A variety of factors including a disease-oriented healthcare system, care priorities, difficulty performing a CBE or mammogram, a lack of insurance, and provider and patient knowledge and attitudes about screening may lead to bias against screening women with mobility anal cognitive limitations. Implications for policy, delivery or practice. Physically inaccessible care sites, inadequate equipment, such as nonadjustable examining tables, and time pressures experienced by providers may impede efforts to provide comprehensive preventive care to women with chronic disabilities. Increasing health care coverage or geographic access may be inadequate if the knowledge and attitudes of providers and patients are not addressed.

African Americans have low rates of colorectal cancer (CRC) screening, and little is known about factors influencing their participation. This study sought to identify variables within the biopsychosocial (BPS) model's three factor groups (biological, psychosocial/behavioral, social) that predicted timely colorectal cancer (CRC) screening ('screening') in African American (AA) men and women aged ≥ 40 in Maryland. A secondary analysis of data from 580 AAs in the 2002 Maryland Cancer Survey (MCS) examined whether biological (age, gender, CRC family history), psychosocial/behavioral (mammogram and prostate specific antigen [PSA] screening history, body mass index, activity level, fruit/vegetable consumption, alcohol, smoking, cancer concern, cancer perceived risk, perception of familial cancer), and social (education, employment, insurance, access to healthcare provider [HCP], and HCP recommendation of fecal occult blood test and/or sigmoidoscopy/colonoscopy) factors predicted screening. Research question 1 examined individuals without CRC family history (N=473) using simultaneous, hierarchical block, and stepwise entry logistic regression analyses of individual and grouped variables. Recommendation of fecal occult blood test (OR 11.90, 95% CI: 6.84, 20.71) and sigmoidoscopy/colonscopy (OR 7.06, 95% CI 4.11, 12.14), moderate/vigorous activity (OR 1.70, 95% CI: 1.02, 2.82), and history of PSA screening (OR 2.81, 95% CI 1.01, 7.81) predicted screening, as did the social factor group. Research question 2 examined individuals with CRC family history (N=86) using the same models. Recommendation of sigmoidoscopy/colonscopy (OR 24.3, 95% CI 5.30, 111.34) and vigorous activity (OR 5.21, 95% CI: 1.09, 24.88) predicted screening, as did the social factor group. The study hypothesis proposing that CRC family history predicted screening when controlling for age, education, and insurance was not supported. Results suggest that HCP recommendation was the most important predictor of screening. The small sample of people with CRC family history and sample characteristics (e.g., insurance) that differed from Maryland demographics limit generalizability. Other potentially important variables (e.g., fatalism) were not in the MCS dataset and therefore could not be examined. Prospective research should examine additional possible predictors of screening, and socioeconomic and other variables that limit access to HCPs. Variables that influence HCPs' recommendations for screening and individuals' adherence to recommendations are also important to investigate.

There are currently no USP performance standards for nebulizers and their associated respiratory solutions. This research sought to establish reliable methodologies for comparing total aerosolized output (TO), output rate (OR) and fine droplet fraction (FDF) between an air-jet and an ultrasonic nebulizer. The nebulized output of an aqueous 0.08% w/v fluorescein solution was collected in a total output collection device and four inertial samplers over 0.5, 2 and 5 minutes. Increases in airflow rate to the air-jet nebulizer resulted in significant increases in output rate and variability. However, no practical increases in fine droplet fraction for the air-jet nebulizer were observed. The determination of fine droplet fraction from an ultrasonic nebulizer was found to be prone to sampler overloading. Results among the impactors showed similar trends, but the data was not interchangeable. Using the validated methods established for characterizing a respiratory solution, a model suspension containing 0.1% w/v fluorescein (to estimate droplet deposition) and known quantities of 1, 3 and 6 mum latex spheres (representing insoluble drug particles) was aerosolized from an air-jet and an ultrasonic nebulizer to determine if differences in the aerosolization mechanism affected droplet and sphere deposition. Nebulized output was collected in a modified Andersen impactor. Samples were analyzed spectrophotometrically and by a Coulter Counter to estimate droplet and sphere deposition, respectively. Theoretical mathematical predictions were compared to experimental findings. Significant differences between nebulizers were observed. In the ultrasonic nebulizer, 99% of the spheres were not aerosolized, which the model did not predict. However, the results more closely followed the model for the air-jet nebulizer, since a substantial fraction of the spheres appeared in the aerosolized output. Any attempt to regulate nebulizer performance standards should consider that dissolved drug or droplet deposition patterns do not necessarily reflect those of undissolved drug particles. This research highlighted several justifications for reliably evaluating nebulizer output characteristics. The presented methods provide a rational basis to evaluate performance of nebulizers and their associated respiratory solutions or suspensions.

Abciximab is an antiplatelet inhibitor used in conjunction with percutaneous revascularization procedures to decrease the risk of ischemic complications such as death, nonfatal MI or subsequent revascularization procedures like angioplasty or CABG. Although the efficacy of abciximab is rarely disputed based on evidence from three large clinical trials, the cost-effectiveness of the drug when used during routine practice has been questioned since it costs approximately $1,350 per patient treated. This study was undertaken to estimate the effectiveness of abciximab in patients treated at University of Maryland Medical System (UMMS) and to estimate the incremental cost-effectiveness ratio (ICER) defined as the cost per event avoided. The composite endpoint consisted of death, MI or subsequent revascularization procedure over 6-months of follow-up. Proportional hazards regression revealed that abciximab was associated with a lower risk of ischemic events among patients with more severe angiographic morphology. Patients who received a shortened infusion of the drug (<10 hours) were at a greater risk of experiencing an event than those who received an infusion for 10-14 hours. Also, patients who underwent coronary stenting were less likely to have an event while patients with multivessel disease or a history of a percutaneous revascularization procedure were at a higher risk of experiencing an event. The cost-effectiveness analysis was performed for a subgroup of patients with more severe coronary morphology using a matched cohort design. The point estimate of the ICER revealed that it cost about $20,680 to prevent an ischemic event over six months in high-risk patients treated with abciximab. Confidence intervals for the ICER were computed using Taylor series approximation, Fieller's theorem and bootstrapping, and were graphically represented with ellipses of equal probability. Overall, the data were consistent with a wide range of plausible estimates due to a relatively small denominator in the ICER.