The role of beliefs in sexual behavior of adolescents: Development and validation of an Adolescent Sexual Expectancies Scale (ASEXS)

This paper reports on the development and psychometric properties of the Adolescent Sexual Expectancies Scale (ASEXS). Data were obtained from three annual longitudinal surveys of youth aged 10 - 17 at the first administration (N = 932 at Wave 3). Confirmatory factor analyses indicated that four correlated factors corresponding to Social Risk, Social Benefit, Health Risk, and Pleasure adequately represented the expectancy items. High alpha coefficients and stability across survey waves indicated good internal and test-retest reliability for these factors. Latent variable autoregressive analyses indicated that Social Risk expectancies predicted changes in sexual behavior over the course of the study. Multi-group analyses established that the measurement and predictive models were equivalent for males and females and across age groups. The ASEXS provides researchers with a useful measure for examining adolescents' expectancy beliefs about the consequences of sexual behavior.

Longitudinal adherence to fecal occult blood testing impacts colorectal cancer screening quality

OBJECTIVES

Existing cross-sectional quality measures for colorectal cancer (CRC) screening do not assess longitudinal adherence and thus may overestimate the quality of care. Our goal was to evaluate the adherence to repeated yearly fecal occult blood tests (FOBTs) in order to better understand the extent to which longitudinal adherence may impact screening quality.

METHODS

This was a retrospective cohort analysis of 1,122,645 patients aged 50-75 years seen at any of the 136 Department of Veterans Affairs medical centers across the United States in 2000 and followed through 2005. The primary outcome was receipt of adequate CRC screening as defined by receipt of FOBTs in at least 4 out of 5 years or receipt of any number of FOBTs in addition to at least one colonoscopy, flexible sigmoidoscopy, or double-contrast barium enema. In a predefined subset of patients receiving exclusively FOBT, adherence with repeated testing was determined over the 5-year study period.

RESULTS

Only 41.1% of men and 43.6% of women received adequate screening. Of the 384,527 men who received exclusively FOBT, 42.1% received a single FOBT, 26.0% received 2 tests, 17.8% received 3 tests, and only 14.1% were documented to have received at least 4 tests during the study period. Among the 10,469 female veterans receiving FOBT alone, rates were similar with only 13.7% completing at least 4 FOBTs in the 5-year study period.

CONCLUSIONS

Adherence to repeated FOBT is low, suggesting that cross-sectional measurements of quality may overestimate the programmatic success of CRC screening.

Barrett's esophagus, esophageal and esophagogastric junction adenocarcinomas: the role of diet

Identification of modifiable risk factors is an attractive approach to primary prevention of esophageal adenocarcinoma (EAC) and esophagogastric junction adenocarcinoma (EGJAC). We conducted a review of the literature to investigate the association between specific dietary components and the risk of Barrett’s esophagus (BE), EAC and EGJAC, supposing diet might be a risk factor for these tumors. Consumption of meat and high-fat meals has been found positively associated with EAC and EGJAC. An inverse association with increased intake of fruit, vegetables and antioxidants has been reported but this association was not consistent across all studies reviewed. Few studies have examined the association between diet and BE. Additional research is needed to confirm the aforementioned association and clarify the mechanisms by which dietary components affect the risk of developing EAC and EGJAC. Future studies could advance our knowledge by emphasizing prospective designs to reduce recall bias, by using validated dietary intake questionnaires and biological measures and by considering important confounders such as gastro-esophageal reflux disease (GERD) symptoms, tobacco and alcohol use, biometrics, physical activity, and socioeconomic factors.

Variation in use of surveillance colonoscopy among colorectal cancer survivors in the United States

BACKGROUND

Clinical practice guidelines recommend colonoscopies at regular intervals for colorectal cancer (CRC) survivors. Using data from a large, multi-regional, population-based cohort, we describe the rate of surveillance colonoscopy and its association with geographic, sociodemographic, clinical, and health services characteristics.

METHODS

We studied CRC survivors enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Eligible survivors were diagnosed between 2003 and 2005, had curative surgery for CRC, and were alive without recurrences 14 months after surgery with curative intent. Data came from patient interviews and medical record abstraction. We used a multivariate logit model to identify predictors of colonoscopy use.

RESULTS

Despite guidelines recommending surveillance, only 49% of the 1423 eligible survivors received a colonoscopy within 14 months after surgery. We observed large regional differences (38% to 57%) across regions. Survivors who received screening colonoscopy were more likely to: have colon cancer than rectal cancer (OR = 1.41, 95% CI: 1.05-1.90); have visited a primary care physician (OR = 1.44, 95% CI: 1.14-1.82); and received adjuvant chemotherapy (OR = 1.75, 95% CI: 1.27-2.41). Compared to survivors with no comorbidities, survivors with moderate or severe comorbidities were less likely to receive surveillance colonoscopy (OR = 0.69, 95% CI: 0.49-0.98 and OR = 0.44, 95% CI: 0.29-0.66, respectively).

CONCLUSIONS

Despite guidelines, more than half of CRC survivors did not receive surveillance colonoscopy within 14 months of surgery, with substantial variation by site of care. The association of primary care visits and adjuvant chemotherapy use suggests that access to care following surgery affects cancer surveillance.

Obesity and receipt of clinical preventive services in veterans

Although obese individuals utilize health care at higher rates than their normal weight counterparts, they may be less likely to receive certain preventive services. We conducted a retrospective cohort study of veterans with visits to 136 national Veterans Affairs (VA) outpatient clinics in the United States in the year 2000. The cohort included 1,699,219 patients: 94% men, 48% white, and 76% overweight or obese. Overweight and obese patients had higher adjusted odds of receiving each of the targeted clinical preventive services as recommended over 5 years compared with normal weight patients. The odds for receiving vaccinations increased linearly with BMI category: influenza (men: odds ratio (OR) = 1.13 for overweight to OR = 1.42 for obese class 3; women: OR = 1.15 for overweight to OR = 1.61 for obese class 3) and pneumococcus (men: OR = 1.02 for overweight to OR = 1.15 for obese class 3; women: OR = 1.08 for overweight to OR = 1.28 for obese class 3). The odds for receiving the cancer screening services typically peaked in the mild-moderately obese categories. The highest OR for prostate cancer screening was in obese class 2 (OR = 1.29); for colorectal cancer, obese class 1 (men: OR = 1.15; women OR = 1.10); for breast cancer screening, obese class 2 (OR = 1.19); and for cervical cancer screening, obese class 2 (OR = 1.06). In a large national sample, obese patients received preventive services at higher, not lower, rates than their normal weight peers. This may be due to the VA health service coverage and performance directives, a more homogeneous patient demographic profile, and/or unmeasured factors related to service receipt.

Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve

Standard endoscopic mucosal resection (EMR) is limited with regard to lesions below or involving the ileocecal valve. We describe the treatment and outcomes when using cap-assisted EMR (EMR-C) to remove large laterally spreading tumors (LSTs) with ileal infiltration in seven patients (median age 74 years). Each LST (median size 40 mm) was successfully resected in one session (median procedure time 50 minutes). Intraprocedural and early bleeding occurred in two patients, and delayed hemorrhage in one. Circumferential resection of the ileum caused asymptomatic strictures in six patients, with regression during follow-up for five. We conclude that the novel EMR-C method is a potentially effective treatment for cecal LST involving the distal ileum. Serious complications such as perforation or symptomatic strictures of the ileocecal valve were not observed and any procedure-related bleeding was easily controlled.

Sex on American Television: An Analysis Across Program Genres and Network Types

As part of a larger study on television exposure, 1,276 shows from the 2001-2002 television season were coded for sexual content. Compared to previous research, this study sampled more networks targeted to adolescents and examined differences across additional program genres. A unique feature is the assessment of sexual content across network types. Three genres were distinguished by high percentages of shows with sexual behavior and talk and greater explicitness. This pattern characterized premium cable movie channels compared to broadcast and other cable networks. Few genres consistently offer programming that is free of sexual content during peak times for teen viewing.

Television Use, Sexual Behavior, and Relationship Status at Last Oral Sex and Vaginal Intercourse

The current longitudinal study explores the relationship between adolescent television use at time 1 and sexual experience and relationship status (i.e., committed/romantic versus casual) 1 year later. The sample (N = 824) comprised youth aged 14-18. Multinomial logistic regressions predicting group membership from television exposure variables were conducted controlling for socio-demographic characteristics and prior sexual behavior. Results indicate that sexually inexperienced youth watched more television overall than sexually experienced youth, but less adult, premium and music television on cable networks. Premium cable exposure predicted group membership among sexually active youth. Youth who watched more premium cable at time 1 were more likely to be in casual relationship at last intercourse than a committed one. A more complete understanding of media effects on adolescent sexual relationships can help guide policy development, media education/literacy efforts, and contribute to the design of interventions to reduce the negative consequences associated with adolescent sexual behavior.

Ascertainment of colonoscopy indication using administrative data

BACKGROUND

Administrative procedure code data can estimate colonoscopy utilization; however, determining colonoscopy indication is more difficult as procedure codes do not inherently reflect the purpose (screening, surveillance, diagnosis) of the colonoscopy.

AIM

To improve the reported sensitivity (70%) and specificity (72%) of a published algorithm for identifying screening colonoscopies using Veterans Health Administration (VHA) administrative data.

METHODS

We validated three algorithms for determining colonoscopy indication using medical records as the gold standard in a national sample of 650 patients. Algorithms used International Classification of Diseases, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Medical records were manually abstracted using standardized protocols.

RESULTS

The best algorithm had 83% sensitivity and 76% specificity for screening indication. Over 99% of colonoscopy CPT codes corresponded to a colonoscopy in the medical record.

CONCLUSIONS

VHA procedure codes are very accurate for colonoscopy utilization; however, algorithms to ascertain indication have only moderate accuracy.

Cap-assisted endoscopic mucosal resection for colorectal polyps

PURPOSE

Cap-assisted endoscopic mucosal resection has been used to treat superficial esophageal and gastric cancers. Efficacy data in the colon are limited. The aim of the study was to evaluate the safety and efficacy of this technique in the treatment of sessile polyps and lateral spreading tumors in the colorectum.

METHODS

Two-hundred and fifty-five consecutive patients with sessile polyps or lateral spreading tumors >or=20 mm were treated between January 2000 and December 2007.

RESULTS

A total of 146 sessile polyps and 136 lateral spreading tumors were treated with cap-assisted endoscopic mucosal resection. Complications occurred in 22 (8.6%) patients (5.5% in sessile polyps and 10.3% in lateral spreading tumors). Intraprocedural bleeding occurred in 21 (7%) of polypectomies (6% in sessile polyps and 10% in lateral spreading tumors); all were controlled endoscopically. Postcoagulation syndrome occurred in 1 patient with lateral spreading tumor. No perforation occurred. Invasive adenocarcinoma was found in 35 patients, of whom 15 underwent surgery. Endoscopic follow-up in 200 patients with 216 adenomas for a median of 12.1 months showed recurrence in 8 (4%) who were treated with resection and/or ablation.

CONCLUSIONS

Cap-assisted endoscopic mucosal resection is an effective treatment for sessile polyps and lateral spreading tumors. A disadvantage of the technique is that the resection is piecemeal. Close surveillance provides the opportunity for additional tissue ablation, when required, to achieve complete lesion removal.

Determinants of medical system delay in the diagnosis of colorectal cancer within the Veteran Affairs Health System

BACKGROUND AND AIMS

The goals of this study are to evaluate determinants of the time in the medical system until a colorectal cancer diagnosis and to explore characteristics associated with stage at diagnosis.

METHODS

We examined medical records and survey data for 468 patients with colorectal cancer at 15 Veterans Affairs medical centers. Patients were classified as screen-detected, bleeding-detected, or other (resulting from the evaluation of another medical concern). Patients who presented emergently with obstruction or perforation were excluded. We used Cox proportional hazards models to determine predictors of time in the medical system until diagnosis. Logistic regression models were used to determine predictors of stage at diagnosis.

RESULTS

We excluded 21 subjects who presented emergently, leaving 447 subjects; the mean age was 67 years and 98% were male, 66% Caucasian, and 43% stage I or II. Diagnosis was by screening for 39%, bleeding symptoms for 27%, and other for 34%. The median times to diagnosis were 73-91 days and were not significantly different by diagnostic category. In the multivariable model for time to diagnosis, older age, having comorbidities, and Atlantic region were associated with a longer time to diagnosis. In the multivariable model for stage-at-diagnosis, only the diagnostic category was associated with stage; the screen-detected category was associated with decreased risk of late-stage cancer.

CONCLUSIONS

Our results point to several factors associated with a longer time from the initial clinical event until diagnosis. This increased time in the health care system did not clearly translate into more advanced disease at diagnosis.

Time from positive screening fecal occult blood test to colonoscopy and risk of neoplasia

There is no guideline defining the optimal time from a positive screening fecal occult blood test to follow-up colonoscopy. We reviewed records of 231 consecutive primary care patients who received a colonoscopy within 18 months of a positive fecal occult blood test. We examined the relationship between time to colonoscopy and risk of neoplasia on colonoscopy using a logistic regression analysis adjusting for potential confounders such as age, race, and gender. The mean time to colonoscopy was 236 days. Longer time to colonoscopy (OR = 1.10, P = 0.01) and older age (OR 1.04, P = 0.01) were associated with higher odds of neoplasia. The association of time with advanced neoplasia was positive, but not statistically significant (OR 1.07, P = 0.14). In this study, a longer interval to colonoscopy after fecal occult blood test was associated with an increased risk of neoplasia. Determining the optimal interval for follow-up is desirable and will require larger studies.

Adrenal Epinephrine and the Regulation of Pulmonary Surfactant Release in Neonatal Rabbits

Adrenergic mechanisms influence surfactant metabolism; however the nature and importance of catechol-mediated regulation is unclear. We designed experiments to assess the role of endogenous adrenal epinephrine (E) synthesis in neonatal alveolar surfactant release. We administered the experimental adrenal epinephrine synthesis inhibitor SKF 29661 to pregnant rabbits to reduce fetal adrenal E content. Surfactant release was measured as total alveolar phosphatidylcholine (PC) content recovered by a thorough alveolar wash performed on animals sacrificed at birth and at 1 h of age. At a maternal dose of 100 mg/kg/day, SKF 29661 caused a 57% reduction in fetal adrenal E content (p less than .01), which was associated with a 40% reduction in alveolar PC at birth and a 23% reduction in alveolar PC at 1 h of age (p less than .01). Moreover, adrenal E correlated positively with total alveolar PC content (p less than .001). These results suggest that in the neonatal period, the ability of the fetal adrenal gland to synthesize E for secretion plays a role in the regulation of pulmonary surfactant release.

The impact of underage drinking laws on alcohol-related fatal crashes of young drivers

BACKGROUND

This study used a pre- to post-design to evaluate the influence on drinking-and-driving fatal crashes of 6 laws directed at youth aged 20 and younger and 4 laws targeting all drivers.

METHODS

Data on the laws were drawn from the Alcohol Policy Information System data set (1998 to 2005), the Digests of State Alcohol Highway Safety Related Legislation (1983 to 2006), and the Westlaw database. The Fatality Analysis Reporting System data set (1982 to 2004) was used to assess the ratio of drinking to nondrinking drivers involved in fatal crashes [fatal crash incidence ratio (CIR)]. The data were analyzed using structural equation modeling techniques.

RESULTS

Significant decreases in the underage fatal CIR were associated with presence of 4 of the laws targeting youth (possession, purchase, use and lose, and zero tolerance) and 3 of the laws targeting all drivers (0.08 blood alcohol concentration illegal per se law, secondary or upgrade to a primary seat belt law, and an administrative license revocation law). Beer consumption was associated with a significant increase in the underage fatal CIR. The direct effects of laws targeting drivers of all ages on adult drinking drivers aged 26 and older were similar but of a smaller magnitude compared to the findings for those aged 20 and younger. It is estimated that the 2 core underage drinking laws (purchase and possession) and the zero tolerance law are currently saving an estimated 732 lives per year controlling for other exposure factors. If all states adopted use and lose laws, an additional 165 lives could be saved annually.

CONCLUSIONS

These results provide substantial support for the effectiveness of under age 21 drinking laws with 4 of the 6 laws examined having significant associations with reductions in underage drinking-and-driving fatal crashes. These findings point to the importance of key underage drinking and traffic safety laws in efforts to reduce underage drinking-driver crashes.

Readiness exercise to combat avian influenza

AIM

To examine the readiness of our hospital for the potential pandemic threat of avian influenza, we developed and implemented simulation case scenarios in our hospital.

METHODS

Two volunteers, who assumed the identity of 'actual' patients, were trained to simulate acute respiratory symptoms following a visit to an avian influenza-affected area, and their identities and locations were kept confidential prior to the readiness exercise. A team of auditors was stationed at high-risk areas to assess adherence to the use of personal protective equipment (PPE) and infection control procedures.

RESULTS

A total of 324 healthcare workers and 84 administrators participated in this hospital-wide exercise. Following disclosure of their symptoms, the 'patients' were masked and isolated in negative-pressure rooms. A quarantine order was enforced on 38 inpatients and 45 healthcare workers who were present in the affected wards at the time of the exercise, which mandated the use of PPE. Although all affected healthcare workers were competent in the use of PPE, we observed breaches in PPE and isolation procedures in eight medical and nursing students, and 10 healthcare attendants. The exercise concluded after H5N1 tests returned negative.

CONCLUSION

We recommend the use of case simulation as an effective means of assessing potential breaches in infection control procedures.

Televised sexual content and parental mediation: Influences on adolescent sexuality

Little research has been conducted to examine the influence of exposure to televised sexual content on adolescent sexuality or how parental intervention may reduce negative effects of viewing such content. This study uses self-report data from 1,012 adolescents to investigate the relations among exposure to sexually suggestive programming, parental mediation strategies, and three types of adolescent sexuality outcomes: participation in oral sex and sexual intercourse, future intentions to engage in these behaviors, and sex expectancies. As predicted, exposure to sexual content was associated with an increased likelihood of engaging in sexual behaviors, increased intentions to do so in the future, and more positive sex expectancies. Often, parental mediation strategies were a significant factor in moderating these potential media influences.

The relationship of underage drinking laws to reductions in drinking drivers in fatal crashes in the United States

This study reports on an effort to evaluate and interrelate the existence and strength of two core laws and 14 expanded laws designed to (a) control the sales of alcohol, (b) prevent possession and consumption of alcohol, and (c) prevent alcohol impaired driving by youth aged 20 and younger. Our first analysis determined if the enactment of the possession and purchase laws (the two core minimum legal drinking age laws) was associated with a reduction in the ratio of drinking to nondrinking drivers aged 20 and younger who were involved in fatal crashes controlling for as many variables as possible. The ANOVA results suggest that in the presence of numerous covariates, the possession and purchase laws account for an 11.2% (p=0.041) reduction in the ratio measure. Our second analysis determined whether the existence and strength of any of the 16 underage drinking laws was associated with a reduction in the percentage of drivers aged 20 and younger involved in fatal crashes who were drinking. In the regression analyses, making it illegal to use a false identification to purchase alcohol was significant. From state to state, a unit difference (increase) in the strength of the False ID Use law was associated with a 7.3% smaller outcome measure (p=0.034).

Validation of self-reported colorectal cancer screening behavior from a mixed-mode survey of veterans

OBJECTIVE

The aim of the study was to validate self-reported colorectal cancer (CRC) screening using the National Cancer Institute Colorectal Cancer Screening questionnaire.

MATERIALS AND METHODS

890 patients, ages 50 to 75 years, from the Minneapolis Veterans Affairs (VA) Medical Center were surveyed by mail. Phone administration was attempted with mail nonresponders. VA and non-VA records were combined for the reference standard. Sensitivity, specificity, concordance, and report-to-records ratio (R2R) were estimated for overall and test-specific CRC adherence among respondents providing complete medical records. Secondary analyses examined variation in estimates by patient characteristics, treatment of missing and uncertain responses, and whether a strict or liberal time interval was used for assessing concordance.

RESULTS

Complete medical records were available for 345 of the 686 survey responders. For overall adherence, sensitivity was 0.98, specificity was 0.59, concordance was 0.88, and R2R was 1.14. Sensitivity was 0.82 for fecal occult blood test (FOBT), 0.75 for sigmoidoscopy, 0.97 for colonoscopy, and 0.63 for double-contrast barium enema (DCBE). Specificity was 0.89 for FOBT, 0.76 for sigmoidoscopy, 0.72 for colonoscopy, and 0.85 for DCBE. Concordance was >0.80 for all tests other than sigmoidoscopy (0.76). R2R was 1.31 for FOBT, 1.33 for sigmoidoscopy, 1.42 for colonoscopy, and 6.13 for DCBE. The R2R was lower for a combined sigmoidoscopy and colonoscopy measure. Overreporting was more pronounced for older, less-educated individuals with no family history of CRC. Sensitivity and R2R improved using a liberal interval and treating uncertain responses as nonadherent (versus missing), but differences were not statistically significant.

CONCLUSIONS

Self-reported CRC screening validity is generally acceptable and robust across definitional decisions, but varies by screening test and patient characteristics.

Parenting practices and adolescent sexual behavior: A longitudinal study

The effects of parental attitudes, practices, and television mediation on adolescent sexual behaviors were investigated in a study of adolescent sexuality and media (N=887). Confirmatory factor analyses supported an eight-factor parenting model with television mediation factors as constructs distinct from general parenting practices. Logistic regressions indicated that adolescents reporting greater parental disapproval and limits on viewing at Wave 1 were less likely to initiate oral sex between Waves 1 and 2. Adolescents who reported more sexual communication with parents were more likely to initiate oral sex. Results for vaginal intercourse were similar to those for oral sex. Co-viewing was a significant negative predictor of initiation of sexual behavior. Parental attitudes and television mediation can delay potentially risky adolescent sexual behaviors.