A Review of Hot Deck Imputation for Survey Non-response

Clinical, Social, and Genetic Factors Associated with Obesity at 12 Months of Age

OBJECTIVE

To examine genomic, social, and clinical risk factors of ≥85 weight for length percentile (WFLP) at 12 months.

STUDY DESIGN

Children in this study had whole-genome sequencing, and clinical and social data were collected. WFLPs at 12 months of age were grouped as follows: (1) <85th, (2) ≥85th to <95th, (3) ≥95th to <99th, and (4) ≥99th. Whole-genome sequencing data were used to analyze rare and common variants, and association of clinical and social factors was examined.

RESULTS

A total of 690 children were included; WFLPs were 422 (61.2%) <85th, 112 (16.2%) ≥85th-<95th, 89 (12.9%) ≥95th-<99th, and 67 (9.7%) ≥99th. Family-related risk factors associated with greater WFLP were greater paternal body mass index, WFLP ≥99th OR 1.10 (1.03-1.16), and greater than recommended weight gain in pregnancy, WFLP ≥85th-<95th OR 1.90 (1.09-3.26). More breast milk at 6 months was protective factor: WFLP ≥85th-<95th, OR 0.98 (0.97-0.99), WFLP ≥95th-<99th OR 0.98 (0.97-0.99), and WFLP ≥99th OR 0.98 (0.96-0.99). Although none of the variants reached genome-wide significance, there was a trend toward increased prevalence of genetic variants within or near genes previously associated with obesity in children with WFLP ≥99th.

CONCLUSION

This cross-sectional study identified several modifiable factors, including increased weight gain in pregnancy and decreased breast milk at 6 months, associated with greater WFLP at 12 months. Strong genetic factors were not identified.

The moderating impact of childhood adversity profiles and conflict on psychological health and suicidal behaviour in the Northern Ireland population

Childhood adversities are key etiological factors in the onset and persistence of psychopathology. In Northern Ireland the Troubles also impacted on the population's psychological health. This study used data from the Northern Ireland Study of Health and Stress a collaborative epidemiological study which used the WMH-CIDI to assess mental health disorders in a nationally representative sample (Part 2, n = 1986). The aims of the study were to assess co-occurrences of childhood adversities and investigate the impact of adversity profiles and conflict experience on psychopathology and suicidal behaviour. Latent Class Analysis uncovered 3 discrete childhood adversity profiles, a low, medium, and high risk class. Individuals from higher risk adversity profiles displayed significantly increased odds of having psychological problems, with conflict exposure also impacting on psychopathology. However, the study revealed that the impact of conflict exposure on suicidal behaviour was moderated by latent class membership and that some adversity may actually be protective. The findings highlight the need to consider that, while adversity can have a negative impact on psychopathology, a lack of adversity early in life may hinder some people from developing adequate coping strategies. Further research is required to identify adversity patterns and other interacting factors that are protective.

The Intolerance of Uncertainty Inventory: Validity and Comparison of Scoring Methods to Assess Individuals Screening Positive for Anxiety and Depression

Intolerance of Uncertainty is a fundamental transdiagnostic personality construct hierarchically organized with a core general factor underlying diverse clinical manifestations. The current study evaluated the construct validity of the Intolerance of Uncertainty Inventory, a two-part scale separately assessing a unitary Intolerance of Uncertainty disposition to consider uncertainties to be unacceptable and threatening (Part A) and the consequences of such disposition, regarding experiential avoidance, chronic doubt, overestimation of threat, worrying, control of uncertain situations, and seeking reassurance (Part B). Community members (N = 1046; Mean age = 36.69 ± 12.31 years; 61% females) completed the Intolerance of Uncertainty Inventory with the Beck Depression Inventory-II and the State-Trait Anxiety Inventory. Part A demonstrated a robust unidimensional structure and an excellent convergent validity with Part B. A bifactor model was the best fitting model for Part B. Based on these results, we compared the hierarchical factor scores with summated ratings clinical proxy groups reporting anxiety and depression symptoms. Summated rating scores were associated with both depression and anxiety and proportionally increased with the co-occurrence of depressive and anxious symptoms. By contrast, hierarchical scores were useful to detect which facets mostly separated between for depression and anxiety groups. In sum, Part A was a reliable and valid transdiagnostic measure of Intolerance of Uncertainty. The Part B was arguably more useful for assessing clinical manifestations of Intolerance of Uncertainty for specific disorders, provided that hierarchical scores are used. Overall, our study suggest that clinical assessments might need to shift toward hierarchical factor scores.

Effects on patients of variations in the implementation of a cardiometabolic risk intervention program in Montréal

INTRODUCTION

In 2011, the Agence de la santé et des services sociaux de Montréal (ASSSM), in partnership with the region's Centres de santé et de services sociaux (CSSS), coordinated the implementation of a program on cardiometabolic risk based on the Chronic Care Model. The program, intended for patients suffering from diabetes or hypertension, involved a series of individual follow-up appointments, group classes and exercise sessions. Our study assesses the impact on patient health outcomes of variations in the implementation of some aspects of the program among the six CSSSs taking part in the study.

METHODS

The evaluation was carried out using a quasi-experimental "before and after" design. Implementation variables were constructed based on data collected during the implementation analysis regarding resources, compliance with the clinical process set out in the regional program, the program experience and internal coordination within the care team. Differences in differences using propensity scores were calculated for HbA1c results, achieving the blood pressure (BP) target, and two lifestyle targets (exercise level and carbohydrate distribution) at the 6- and 12-month follow-ups, based on greater or lesser patient exposure to the implementation of various aspects of the program under study.

RESULTS

The results focus on 1185 patients for whom we had data at the 6-month follow- up and the 992 patients from the 12-month follow-up. The difference in differences analysis shows no clear association between the extent of implementation of the various aspects of the program under study and patient health outcomes.

CONCLUSION

The program produces effects on selected health indicators independent of variations in program implementation among the CSSSs taking part in the study. The results suggest that the effects of this type of program are more highly dependent on the delivery of interventions to patients than on the organizational aspects of its implementation.

Use of Acupuncture in the United States Military Healthcare System

Objectives: The Military Healthcare System (MHS) shows increasing interest in acupuncture as an alternative to opioids for pain control. However, specific factors associated with this procedure in the MHS are not well-described in literature. This study examines usage within the MHS to determine patterns among the diagnoses, provider types, and facilities associated with acupuncture. Materials and Methods: Acupuncture-treated patients were identified from TRICARE claims data in the MHS Data Repository as having at least one acupuncture treatment in fiscal year (FY) 2014. Bivariate analysis was performed to determine demographics, diagnoses, and number of visits, for both active-duty and nonactive-duty personnel. Descriptive statistics were used to show associated provider and facility types. Results: A total of 15,761 people received acupuncture in the MHS in FY 2014. Use of acupuncture was greater for Army service, white race, and senior enlisted rank overall, and for males ages 26-35 among active-duty and females ages 46-64 among nonactive-duty beneficiaries. A cumulative 76% of diagnoses were for musculoskeletal or nerve and system issues. Approximately 60% of patients received acupuncture from physicians, 16% from physical therapists or chiropractors, and 9.7% from physician extenders. Specific acupuncture techniques (traditional, auricular, etc.) could not be determined from the data set. Conclusions: The most common diagnoses associated with acupuncture are consistent with pain management. However, full analysis is hampered by inconsistent coding and lack of granularity regarding specific techniques. Given the popularity of acupuncture in the MHS, further research is necessary to explore the full scope of this intervention.

Communicating with Daughters About Familial Risk of Breast Cancer: Individual, Family, and Provider Influences on Women's Knowledge of Cancer Risk

INTRODUCTION

Women facing complex and uncertain situations such as cancer in their families may seek information from a variety of sources to gain knowledge about cancer risk and reduce uncertainty. We describe and assess the relative importance of information sources about familial breast cancer at the individual, family, and healthcare provider levels influencing women's reporting they had enough information to speak with daughters about breast cancer. This outcome we refer to as being informed about breast cancer.

MATERIALS AND METHODS

Sister Study participants, a cohort of women with a family history of breast cancer, were surveyed on family cancer history, family communication, social support, and interactions with healthcare providers (n = 11,766). Adjusted percentages and 95% confidence intervals for being informed about breast cancer versus not being informed were computed for individual-, family-, and provider-level characteristics in three steps using multivariate logistic regression models.

RESULTS

We found 65% of women reported being informed about breast cancer while 35% did not. Having a trusted person with whom to discuss cancer concerns, having a lower versus higher perceived risk of breast cancer, having undergone genetic counseling, and being satisfied with physician discussions about breast cancer in their families were predictors of being informed about breast cancer.

CONCLUSIONS

Although acquiring objective risk information, such as through genetic counseling, may contribute to a basic level of understanding, communication with providers and within other trusted relationships appears to be an essential component in women's reporting they had all the information they need to talk with their daughters about breast cancer.

Patient portals and personal health information online: perception, access, and use by US adults

Background

Access to online patient portals is key to improving care, but we have limited understanding of patient perceptions of online portals and the characteristics of people who use them.

Methods

Using a national survey of 3677 respondents, we describe perceptions and utilization of online personal health information (PHI) portals.

Results

Most respondents (92%) considered online PHI access important, yet only 34% were offered access to online PHI by a health care provider, and just 28% accessed online PHI in the past year. While there were no differences across race or ethnicity in importance of access, black and Hispanic respondents were significantly less likely to be offered access ( P  = .006 and <.001, respectively) and less likely to access their online PHI ( P  = .041 and <.001, respectively) compared to white and non-Hispanic respondents.

Conclusion

Health care providers are crucial to the adoption and use of online patient portals and should be encouraged to offer consistent access regardless of patient race and ethnicity.

Multiple Imputation by Predictive Mean Matching When Sample Size Is Small

Abstract. Predictive mean matching (PMM) is a state-of-the-art hot deck multiple imputation (MI) procedure. The quality of its results depends, inter alia, on the availability of suitable donor cases. Applying PMM in small sample scenarios often found in psychological or medical research could be problematic, as there might not be many (or any) suitable donor cases in the data set. So far, there has not been any systematic research that examined the performance of PMM, when sample size is small. The present study evaluated PMM in various multiple regression scenarios, where sample size, missing data percentages, the size of the regression coefficients, and PMM’s donor selection strategy were systematically varied. Results show that PMM could be used in most scenarios, however results depended on the donor selection strategy: overall, PMM using either automatic distance-aided selection of donors ( Gaffert, Meinfelder, & Bosch, 2016 ) or using the nearest neighbor produced the best results.

The Hippo transducers TAZ/YAP and their target CTGF in male breast cancer

Male breast cancer (MBC) is a rare disease and its biology is poorly understood. Deregulated Hippo pathway promotes oncogenic functions in female breast cancer. We herein investigated the expression of the Hippo transducers TAZ/YAP and their target CTGF in MBC. Tissue microarrays containing samples from 255 MBC patients were immunostained for TAZ, YAP and CTGF. One hundred and twenty-nine patients were considered eligible. The Pearson's Chi-squared test of independence was used to test the association between categorical variables. The correlation between TAZ, YAP and CTGF was assessed with the Pearson's correlation coefficient. The Kaplan-Meier method and the log-rank test were used for estimating and comparing survival curves. Cox proportional regression models were built to identify variables impacting overall survival. Statistical tests were two-sided. Tumors were considered to harbor active TAZ/YAP-driven gene transcription when they co-expressed TAZ, or YAP, and CTGF. Patients whose tumors had the TAZ/CTGF and YAP/CTGF phenotypes experienced shorter overall survival compared with their negative counterparts (log rank p = 0.036 for both). TAZ/CTGF and YAP/CTGF tumors were associated with decreased survival in patients with invasive ductal carcinomas, G3 tumors, hormone receptor-positive tumors, and tumors with elevated Ki-67. Multivariate analyses confirmed that the TAZ/CTGF and YAP/CTGF phenotypes are independent predictors of survival (HR 2.03, 95% CI: 1.06-3.90, p = 0.033; and HR 2.00, 95% CI: 1.04-3.84, p = 0.037 respectively). Comparable results were obtained when excluding uncommon histotypes (TAZ/CTGF: HR 2.34, 95% CI: 1.16-4.73, p = 0.018. YAP/CTGF. HR 2.36, 95% CI: 1.17-4.77, p = 0.017). Overall, the TAZ/YAP-driven oncogenic program may be active in MBC, conferring poorer survival.

On Inverse Probability Weighting for Nonmonotone Missing at Random Data

The development of coherent missing data models to account for nonmonotone missing at random (MAR) data by inverse probability weighting (IPW) remains to date largely unresolved. As a consequence, IPW has essentially been restricted for use only in monotone missing data settings. We propose a class of models for nonmonotone missing data mechanisms that spans the MAR model, while allowing the underlying full data law to remain unrestricted. For parametric specifications within the proposed class, we introduce an unconstrained maximum likelihood estimator for estimating the missing data probabilities which can be easily implemented using existing software. To circumvent potential convergence issues with this procedure, we also introduce a Bayesian constrained approach to estimate the missing data process which is guaranteed to yield inferences that respect all model restrictions. The efficiency of the standard IPW estimator is improved by incorporating information from incomplete cases through an augmented estimating equation which is optimal within a large class of estimating equations. We investigate the finite-sample properties of the proposed estimators in a simulation study and illustrate the new methodology in an application evaluating key correlates of preterm delivery for infants born to HIV infected mothers in Botswana, Africa.

Bridging observational studies and randomized experiments by embedding the former in the latter

Consider a statistical analysis that draws causal inferences from an observational dataset, inferences that are presented as being valid in the standard frequentist senses; i.e. the analysis produces: (1) consistent point estimates, (2) valid p-values, valid in the sense of rejecting true null hypotheses at the nominal level or less often, and/or (3) confidence intervals, which are presented as having at least their nominal coverage for their estimands. For the hypothetical validity of these statements, the analysis must embed the observational study in a hypothetical randomized experiment that created the observed data, or a subset of that hypothetical randomized data set. This multistage effort with thought-provoking tasks involves: (1) a purely conceptual stage that precisely formulate the causal question in terms of a hypothetical randomized experiment where the exposure is assigned to units; (2) a design stage that approximates a randomized experiment before any outcome data are observed, (3) a statistical analysis stage comparing the outcomes of interest in the exposed and non-exposed units of the hypothetical randomized experiment, and (4) a summary stage providing conclusions about statistical evidence for the sizes of possible causal effects. Stages 2 and 3 may rely on modern computing to implement the effort, whereas Stage 1 demands careful scientific argumentation to make the embedding plausible to scientific readers of the proffered statistical analysis. Otherwise, the resulting analysis is vulnerable to criticism for being simply a presentation of scientifically meaningless arithmetic calculations. The conceptually most demanding tasks are often the most scientifically interesting to the dedicated researcher and readers of the resulting statistical analyses. This perspective is rarely implemented with any rigor, for example, completely eschewing the first stage. We illustrate our approach using an example examining the effect of parental smoking on children's lung function collected in families living in East Boston in the 1970s.

[Psycho-oncology care in rural areas : Results from a cross-sectional survey on the utilisation of community-based psychosocial support services]

BACKGROUND

Clinically relevant distress and unmet psychosocial needs frequently occur in the course of cancer diseases. Particularly for thinly populated rural areas in Germany rates of distressed patients and uptake of community-based psycho-oncology services are unknown.

OBJECTIVES

Determination of a) the proportion of cancer patients with psychosocial distress and unmet needs and b) the utilisation of community-based psycho-oncology services in thinly populated rural areas.

MATERIALS AND METHODS

Prospective cross-sectional study of 229 cancer patients (colon, breast, prostate cancer) living in thinly populated rural areas. Indicators for clinically relevant distress and utilisation of psychosocial services were assessed by applying screening instruments. We conducted descriptive and multivariate analyses.

RESULTS

More than one third of all cancer patients (39.3%) in thinly populated areas exhibited clinically relevant distress. However, only 15.6% of distressed patients consulted community-based psycho-oncology services. Most frequently, medical or psychological psychotherapists were contacted. Information deficits of patients and attending physicians alongside dispositional factors emerged as the main reasons for non-utilisation.

DISCUSSION

This study presents first data on psycho-oncology care in rural areas in Germany stratifying the degree of urbanisation in line with the standards of the European Commission. Concerning limitations, we only accounted for structural service coverage, leaving aside other indicators for socio-spatial deprivation.

Infrequent Provision of Palliative Care to Patients with Dialysis-Requiring AKI

BACKGROUND AND OBJECTIVES

The use of palliative care in AKI is not well described. We sought to better understand palliative care practice patterns for hospitalized patients with AKI requiring dialysis in the United States.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the 2012 National Inpatient Sample, we identified patients with AKI and palliative care encounters using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared palliative care encounters in patients with AKI requiring dialysis, patients with AKI not requiring dialysis, and patients without AKI. We described the provision of palliative care in patients with AKI requiring dialysis and compared the frequency of palliative care encounters for patients with AKI requiring dialysis with that for patients with other illnesses with similarly poor prognoses. We used logistic regression to determine factors associated with the provision of palliative care, adjusting for demographics, hospital-level variables, and patient comorbidities.

RESULTS

We identified 3,031,036 patients with AKI, of whom 91,850 (3%) received dialysis. We observed significant patient- and hospital-level differences in the provision of palliative care for patients with AKI requiring dialysis; adjusted odds were 26% (95% confidence interval, 12% to 38%) lower in blacks and 23% (95% confidence interval, 3% to 39%) lower in Hispanics relative to whites. Lower provision of palliative care was observed for rural and urban nonteaching hospitals relative to urban teaching hospitals, small and medium hospitals relative to large hospitals, and hospitals in the Northeast compared with the South. After adjusting for age and sex, there was low utilization of palliative care services for patients with AKI requiring dialysis (8%)-comparable with rates of utilization by patients with other illnesses with poor prognosis, including cardiogenic shock (9%), intracranial hemorrhage (10%), and acute respiratory distress syndrome (10%).

CONCLUSIONS

The provision of palliative care varied widely by patient and facility characteristics. Palliative care was infrequently used in hospitalized patients with AKI requiring dialysis, despite its poor prognosis and the regular application of life-sustaining therapy.

Beyond education and income: Identifying novel socioeconomic correlates of cigarette use in U.S. young adults

Young adulthood is defined by transitions in family life, living situations, educational settings, and employment. As a result, education and income may not be appropriate measures of socioeconomic status (SES) in young people. Using a national sample of young adults aged 18-34 (n=3364; collected February 2016), we explored novel socioeconomic correlates of ever cigarette use, past 30-day cigarette use, and daily cigarette use, weighted to account for non-response. Measures of SES assessed current education, household income, employment status, and subjective financial situation (SFS) and childhood SES (maternal and paternal education, SFS during childhood, parental divorce before age 18). Parental smoking during childhood was examined in sensitivity analyses. The highest prevalence of ever cigarette use was in young adults whose parents divorced before age 18 (57% vs. 47% overall). In general, current education, subjective financial status, and parental education were inversely correlated with past 30-day and daily cigarette use in bivariate analyses. In multivariable Poisson regression models controlling for age, gender, race/ethnicity, and other SES measures, lower education and poorer SFS were most strongly correlated with ever and past 30-day cigarette use. Lower maternal education emerged as the strongest correlate of daily smoking, conferring a twofold higher prevalence of daily smoking compared to maternal education of a Bachelor's degree or greater. Current household income was not a strong predictor of any cigarette use outcome. Novel measures like SFS may improve estimates of socioeconomic disadvantage during this developmental stage.

Making an unknown unknown a known unknown: Missing data in longitudinal neuroimaging studies

The analysis of longitudinal neuroimaging data within the massively univariate framework provides the opportunity to study empirical questions about neurodevelopment. Missing outcome data are an all-to-common feature of any longitudinal study, a feature that, if handled improperly, can reduce statistical power and lead to biased parameter estimates. The goal of this paper is to provide conceptual clarity of the issues and non-issues that arise from analyzing incomplete data in longitudinal studies with particular focus on neuroimaging data. This paper begins with a review of the hierarchy of missing data mechanisms and their relationship to likelihood-based methods, a review that is necessary not just for likelihood-based methods, but also for multiple-imputation methods. Next, the paper provides a series of simulation studies with designs common in longitudinal neuroimaging studies to help illustrate missing data concepts regardless of interpretation. Finally, two applied examples are used to demonstrate the sensitivity of inferences under different missing data assumptions and how this may change the substantive interpretation. The paper concludes with a set of guidelines for analyzing incomplete longitudinal data that can improve the validity of research findings in developmental neuroimaging research.

Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?

INTRODUCTION

Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control.

METHODS

We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes.

RESULTS

A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results.

CONCLUSION

Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

Information Needs Assessment for K-12 School Nurses in Rural Eastern Washington State

School nurses are an often-overlooked population of health care professionals who have great importance in rural communities where access to health care is limited. In order to better serve school nurses in rural eastern Washington, an assessment was conducted to determine their information needs, behaviors, and perceptions. Results indicated this population of school nurses searches for multiple types of health information on a daily basis and navigates obstacles to information access using a variety of resources. While largely confident in their searching ability, they are open to learning more about how to find reliable health information to support their daily responsibilities. These results will guide the development of a workshop for school nurses about using reliable health information resources to improve health care in their rural communities.

Evaluation of large-group lectures in medicine - development of the SETMED-L (Student Evaluation of Teaching in MEDical Lectures) questionnaire

BACKGROUND

The seven categories of the Stanford Faculty Development Program (SFDP) represent a framework for planning and assessing medical teaching. Nevertheless, so far there is no specific evaluation tool for large-group lectures that is based on these categories. This paper reports the development and psychometric validation of a short German evaluation tool for large-group lectures in medical education (SETMED-L: 'Student Evaluation of Teaching in MEDical Lectures') based on the SFDP-categories.

METHODS

Data were collected at two German medical schools. In Study 1, a full information factor analysis of the new 14-item questionnaire was performed. In Study 2, following cognitive debriefings and adjustments, a confirmatory factor analysis was performed. The model was tested for invariance across medical schools and student gender. Convergent validity was assessed by comparison with results of the FEVOR questionnaire.

RESULTS

Study 1 (n = 922) yielded a three-factor solution with one major (10 items) and two minor factors (2 items each). In Study 2 (n = 2740), this factor structure was confirmed. Scale reliability ranged between α = 0.71 and α = 0.88. Measurement invariance was given across student gender but not across medical schools. Convergent validity in the subsample tested (n = 246) yielded acceptable results.

CONCLUSION

The SETMED-L showed satisfactory to very good psychometric characteristics. The main advantages are its short yet comprehensive form, the integration of SFDP-categories and its focus on medical education.

GTSP1 expression in non-smoker and non-drinker patients with squamous cell carcinoma of the head and neck

Introduction

The main risk factors for head and neck squamous cell carcinoma (HNSCC) are tobacco and alcohol consumption and human papillomavirus (HPV) infection. However, in a subset of patients, no risk factors can be identified. Glutathione S-transferase π (GTSP1) is a carcinogen-detoxifying enzyme that is activated by exposure to carcinogens, and it is associated with a reduction in response to toxic therapies. We studied the expression of GTSP1 in tumor and non-tumor tissue samples from patients with and without these risks to identify whether GTSP1 expression differs according to exposure to carcinogens.

Materials and methods

Non-smoker/non-drinker (NSND) and smoker/drinker (SD) patients were matched according to age, gender, tumor site, TNM stage, grade and histological variants to establish 47 pairs of patients who have been previously tested for HPV. GTSP1 immunostaining was analyzed using a semi-quantitative method with scores ranging from 0 to 3 according to the area of immunostaining.

Results

GTSP1 expression was detected in the tumors of both groups. GTSP1 expression was higher in the non-tumor margins of SD patients (p = 0.004). There was no association between GTSP1 expression and positivity for HPV. No differences in survival were observed according to GTSP1 staining in tumors and non-tumor margins.

Conclusion

This study showed that GTSP1 was expressed in tumors of HNSCC patients regardless of smoking, drinking or HPV infection status. The difference in GTSP1 expression in non-tumor margins between the two groups may have been due to two possible reasons. First, elevated GTSP1 expression in SD patients might be the result of activation of GTSP1 in response to exposure to carcinogens. Second, alternatively, impairment in the detoxifying system of GTSP1, as observed by the reduced expression of GTSP1, might make patients susceptible to carcinogens other than tobacco and alcohol, which may be the underlying mechanism of carcinogenesis in the absence of risk factors.

Evaluation in undergraduate medical education: Conceptualizing and validating a novel questionnaire for assessing the quality of bedside teaching

BACKGROUND

Evaluation is an integral part of curriculum development in medical education. Given the peculiarities of bedside teaching, specific evaluation tools for this instructional format are needed. Development of these tools should be informed by appropriate frameworks. The purpose of this study was to develop a specific evaluation tool for bedside teaching based on the Stanford Faculty Development Program's clinical teaching framework.

METHODS

Based on a literature review yielding 47 evaluation items, an 18-item questionnaire was compiled and subsequently completed by undergraduate medical students at two German universities. Reliability and validity were assessed in an exploratory full information item factor analysis (study one) and a confirmatory factor analysis as well as a measurement invariance analysis (study two).

RESULTS

The exploratory analysis involving 824 students revealed a three-factor structure. Reliability estimates of the subscales were satisfactory (α = 0.71-0.84). The model yielded satisfactory fit indices in the confirmatory factor analysis involving 1043 students.

DISCUSSION

The new questionnaire is short and yet based on a widely-used framework for clinical teaching. The analyses presented here indicate good reliability and validity of the instrument. Future research needs to investigate whether feedback generated from this tool helps to improve teaching quality and student learning outcome.

Latent classes of older foster youth: Prospective associations with outcomes and exits from the foster care system during the transition to adulthood

Youth in the foster care system face considerable challenges during the transition to adulthood. However, there is significant variability within this population. This study uses person-oriented methods and a longitudinal dataset of youth aging out of foster care to examine differences in how subgroups of foster youth fare during the transition to adulthood. We identified four distinct latent classes, consistent with prior person-oriented studies of this population, and validated these classes by examining differences on additional relevant factors at age 17. After establishing these classes, we tested their predictive validity by examining differences in outcomes at age 19 in domains relevant to the transition to adulthood, including education and employment, problem behaviors, and mental health problems. Finally, given the importance of extended foster care in promoting better outcomes, we used survival analysis to prospectively examine whether class membership was associated with differences in the rates at which youth left foster care between ages 17 and 19. One large group of youth exhibited moderate behavior problems and left care quickly, while another large group of resilient youth had favorable outcomes and left care relatively slowly. A small group exhibited considerable behavior and mental health problems, but left care more slowly, and a very small group was characterized by a history of pregnancy. Findings suggest considerable variability in service need among older foster youth. Implications for service provision during the transition to adulthood are discussed.

Usual Alcohol Consumption and Risks for Nonfatal Fall Injuries in the United States: Results From the 2004-2013 National Health Interview Survey

BACKGROUND

Acute alcohol consumption is known to be a risk factor for fall injuries.

OBJECTIVE

The study sought to determine whether usual alcohol consumption increases the risk for nonfatal fall injuries.

METHOD

Data from 289,187 sample adults in the 2004-2013 U.S. National Health Interview Surveys were analyzed. Of these, 3,368 (∼1%) reported a total of 3,579 fall-injury episodes requiring medical consultation in the past 3 months. Latent class analysis based on four contextual indicators identified four ecological subtypes of fall injury within two age groups (18-49 and 50+). Five drinking patterns (i.e., lifetime abstainer, former drinker, low-risk drinker, increased-risk drinker, and highest-risk drinker) were categorized according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) low-risk drinking guidelines. Controlling for potential confounders, negative binomial regression estimated the adjusted rates of any type and subtypes of fall injury, by gender, for each drinking pattern relative to lifetime abstainer.

RESULTS

Compared with lifetime abstainers, the adjusted rate of any fall injury for adults ages 18-49 was significantly higher among highest-risk drinkers (men: incidence rate ratio [IRR] = 2.59, 95% confidence interval [CI] [1.60, 4.20]; women: IRR = 1.90, 95% CI [1.24, 2.91]) and increased-risk drinkers (men: IRR = 1.94, 95% CI [1.25, 3.00]; women: IRR = 1.51, 95% CI [1.11, 2.07]). Furthermore, highest-risk drinkers had higher adjusted rates of either leisure- or sports-related fall injuries than lifetime abstainers.

CONCLUSIONS

Alcohol consumption exceeding NIAAA's low-risk drinking guidelines is associated with elevated rates of nonfatal fall injuries. Findings underscore the importance of adhering to these recommendations.

A menu-driven software package of Bayesian nonparametric (and parametric) mixed models for regression analysis and density estimation

Most of applied statistics involves regression analysis of data. In practice, it is important to specify a regression model that has minimal assumptions which are not violated by data, to ensure that statistical inferences from the model are informative and not misleading. This paper presents a stand-alone and menu-driven software package, Bayesian Regression: Nonparametric and Parametric Models, constructed from MATLAB Compiler. Currently, this package gives the user a choice from 83 Bayesian models for data analysis. They include 47 Bayesian nonparametric (BNP) infinite-mixture regression models; 5 BNP infinite-mixture models for density estimation; and 31 normal random effects models (HLMs), including normal linear models. Each of the 78 regression models handles either a continuous, binary, or ordinal dependent variable, and can handle multi-level (grouped) data. All 83 Bayesian models can handle the analysis of weighted observations (e.g., for meta-analysis), and the analysis of left-censored, right-censored, and/or interval-censored data. Each BNP infinite-mixture model has a mixture distribution assigned one of various BNP prior distributions, including priors defined by either the Dirichlet process, Pitman-Yor process (including the normalized stable process), beta (two-parameter) process, normalized inverse-Gaussian process, geometric weights prior, dependent Dirichlet process, or the dependent infinite-probits prior. The software user can mouse-click to select a Bayesian model and perform data analysis via Markov chain Monte Carlo (MCMC) sampling. After the sampling completes, the software automatically opens text output that reports MCMC-based estimates of the model's posterior distribution and model predictive fit to the data. Additional text and/or graphical output can be generated by mouse-clicking other menu options. This includes output of MCMC convergence analyses, and estimates of the model's posterior predictive distribution, for selected functionals and values of covariates. The software is illustrated through the BNP regression analysis of real data.

Using multiple imputation to address the inconsistent distribution of a controlling variable when modeling an infrequent outcome

Temporal changes in methods for collecting longitudinal data can generate inconsistent distributions of affected variables, but effects on parameter estimates have not been well described. We examined differences in Apgar scores of infants born in 2000-2006 to women with ovulatory dysfunction (risk) or tubal obstruction (reference) who underwent assisted reproductive technology (ART), using Florida, Massachusetts, and Michigan birth certificate data linked to the Centers for Disease Control and Prevention's National ART Surveillance System database. Florida had inconsistent information on induction of labor (a control variable) from a 2004 change in birth certificate format. Because we wanted to control for bias that may be introduced by the inconsistent distribution of labor induction in analysis, we used multiple imputation data in analysis. We used Cox-Iannacchione weighted sequential hot deck method to conduct multiple imputation for the labor induction values in Florida data collected before this change, and missing values in Florida data collected after the change and overall Massachusetts and Michigan data. The adjusted odds ratios for low Apgar score were 1.94 (95% confidence interval [CI] 1.32-2.85) using imputed induction of labor and 1.83 (95% CI 1.20-2.80) using not imputed induction of labor. Compared with the estimate from multiple imputation, the estimate obtained using not imputed induction of labor was biased towards the null with inflated standard errors, but the magnitude of differences was small.

Analysis of Health Care Costs in Elderly Patients with Multiple Chronic Conditions Using a Finite Mixture of Generalized Linear Models

In this paper we analysed healthcare costs in a sample of elderly patients suffering from multimorbidity. On the one hand, multimorbid individuals consume a disproportionally large share of healthcare resources. On the other hand, the patient specific number and combination of co-occurring single diseases result in inhomogeneous data leading to biased estimates when using traditional regression techniques. Therefore, we applied a mixture of regressions in order to control for unobserved heterogeneity focussing on the identification of multimorbidity patterns. We used a subsample of N = 1050 patients from a multicentre prospective cohort study of randomly selected multimorbid primary care patients aged 65 to 85 years in Germany (ISRCTN 89818205) who completed a detailed questionnaire on healthcare utilization during the 6-month period preceding the interview. Disease combinations of 1047 were included. We detected four different groups of patients with regard to total costs. These groups corresponded largely to findings from the epidemiological literature. The effect of the presence of an additional disease on costs differed between groups. Moreover, two diametrically opposed cost trends were detected with respect to the number of co-occurring diseases. While in one group costs increased with the number of co-occurring diseases, in a second group cost tended to decrease. Copyright © 2016 John Wiley & Sons, Ltd.

MIFuzzy Clustering for Incomplete Longitudinal Data in Smart Health

Missing data are common in longitudinal observational and randomized controlled trials in smart health studies. Multiple-imputation based fuzzy clustering is an emerging non-parametric soft computing method, used for either semi-supervised or unsupervised learning. Multiple imputation (MI) has been widely-used in missing data analyses, but has not yet been scrutinized for unsupervised learning methods, although they are important for explaining the heterogeneity of treatment effects. Built upon our previous work on MIfuzzy clustering, this paper introduces the MIFuzzy concepts and performance, theoretically, empirically and numerically demonstrate how MI-based approach can reduce the uncertainty of clustering accuracy in comparison to non- and single-imputation based clustering approach. This paper advances our understanding of the utility and strength of MIFuzzy clustering approach to processing incomplete longitudinal behavioral intervention data.

Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities

BACKGROUND

To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC).

METHODS

A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%.

RESULTS

Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients.

CONCLUSIONS

Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017;123:3186-94. © 2017 American Cancer Society.

Effectiveness of the live attenuated and the inactivated influenza vaccine in two-year-olds - a nationwide cohort study Finland, influenza season 2015/16

Although widely recommended, influenza vaccination of children is part of the national vaccination programme only in few countries. In addition to Canada and the United States (US), in Europe Finland and the United Kingdom have introduced live attenuated influenza vaccine (LAIV) for healthy children in their programmes. On 22 June 2016, the US Advisory Committee on Immunizations Practices, voted against further use of LAIV due to no observed vaccine effectiveness (VE) over three consecutive influenza seasons (2013/14 to 2015/16). We summarise the results of a nationwide, register-based cohort study (N=55,258 of whom 8,086 received LAIV and 4,297 TIV); all outcome (laboratory-confirmed influenza), exposure (vaccination) and confounding variable data were retrieved from four computerised national health registers, which were linked via a unique personal identity code assigned to all permanent Finnish residents regardless of nationality. Our study provides evidence of moderate effectiveness against any laboratory-confirmed influenza of the quadrivalent LAIV vaccine (VE: 51%; 95% confidence interval (CI): 28–66%) as well as the inactivated trivalent vaccine (VE: 61%; 95% CI: 31–78%) among two-year-olds during the influenza season 2015/16 in Finland. Based on these data, Finland will continue using LAIV for young children in its National Immunisation Programme this coming influenza season.

Expectations Regarding Aging, Physical Activity, and Physical Function in Older Adults

Objective: The present study examined how expectations regarding aging (ERA) influence physical activity participation and physical function. Method: We surveyed 148 older adults about their ERA (ERA-38), health-promoting lifestyles (HPLP-II), and self-rated health (RAND-36). We tested the mediating effect of physical activity on the relationships between ERA and physical function. Results: Positive expectations were associated with more engagement in physical activity (B = 0.016, p < .05) and better physical function (B = 0.521, p < .01). Physical activity mediated the relationship between ERA and physical function (B = 5.890, p < .01, indirect effect 0.092, CI = [0.015, 0.239]). Discussion: ERA play an important role in adoption of physically active lifestyles in older adults and may influence health outcomes, such as physical function. Future research should evaluate whether attempts to increase physical activity are more successful when modifications to ERA are also targeted.

Depression and infrequent participation in social activities among older adults: the moderating role of high-quality familial ties

OBJECTIVES

The primary objective of this study is to investigate whether depression is associated with reduced participation in social activities among older adults. Additionally, this study assesses whether high-quality familial ties diminish the negative association between depression and social activities.

METHODS

Using cross-sectional telephone interview data from a sample of individuals 60 years of age and older in Arizona and Florida (N = 2000), this study estimates a series of linear regression models to assess the relationship between depression and social activities, and test whether this association is conditioned by high-quality familial ties using multiplicative interaction terms.

RESULTS

As expected, an inverse relationship between depression and social activities is observed. Delving deeper, the regression models reveal that the depression-inactivity association is weaker among older individuals with strong, positive ties to spouses and children. Additional tests demonstrate the mere of existence of familial bonds provides no meaningful benefit - the quality of such ties matters.

CONCLUSION

Findings support the theoretical argument that high-quality familial ties provide supportive coping resources that buffer individuals from the undesirable consequences associated with depression. Moving forward, longitudinal research on the causal links between depression and infrequent participation in social and leisure activities among older adults is warranted.

Long-term exposure to ambient air pollution and mortality in a Chinese tuberculosis cohort

BACKGROUND

Evidence for the relationship between exposure to ambient air pollution and the mortality of tuberculosis (TB) patients is limited.

METHODS

We analyzed the association between long-term exposure to particulate matter <2.5μm in diameter (PM_2.5) and cause-specific mortality in a Chinese TB patients cohort from 2003 to 2013. Data from the Global Burden of Disease 2013 estimate were used to assess yearly average concentrations of PM_2.5 and ozone at the household addresses of participants. Cox regression was used to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for cause-specific mortality, controlling for demographic and other TB-related factors.

RESULTS

There were 4444 eligible subjects, including 891 deaths, over a median follow-up of 2464days. Per an interquartile range increase (2.06μg/m³), multivariable analysis indicated that exposure to PM_2.5 was significantly associated with overall mortality (aHR=1.30, 95% CI: 1.19, 1.42), mortality from TB (aHR=1.46, 95% CI: 1.15, 1.85), respiratory cancers (aHR=1.72, 95% CI: 1.36, 2.19), other respiratory diseases (aHR=1.19, 95% CI: 1.02, 1.38), and other cancers (aHR=1.76, 95% CI: 1.33, 2.32).

CONCLUSIONS

Long-term exposure to PM_2.5 increases the risk of death from TB and other diseases among TB patients. It suggests that the control of ambient air pollution may help decreasing the mortality caused by TB.

Beneficial and limiting factors for return to work following anterior cruciate ligament reconstruction: a retrospective cohort study

PURPOSE

Evidence-based advice for return to work (RTW) after anterior cruciate ligament (ACL) reconstruction is not available. Therefore, the objectives of this study were to determine when patients achieve full RTW, and to explore the beneficial and limiting factors for fully RTW after ACL reconstruction.

METHODS

A retrospective cohort study was performed after ACL reconstruction among 185 patients in one hospital. Data from patient files and a questionnaire were used to explore whether patient-, injury-, surgery-, sports-, work- and rehabilitation-related factors are beneficial or limiting for fully RTW after ACL reconstruction, using a backward stepwise logistic regression analysis.

RESULTS

Of the 125 (68%) patients that returned the questionnaire, 36 were not part of the working population. Of the remaining 89 patients, 82 patients (92%) had returned fully to work at follow-up. The median time to fully RTW was 78 days. In the final regression model, which explained 29% of the variance, a significant OR of 5.4 (90% CI 2.2-13.1) for RTW > 78 days was observed for patients performing heavy knee-demanding work compared to patients performing light knee-demanding work. In addition, a significant and positive OR (1.6, 90% CI 1.2-1.9) for the number of weeks walking with the aid of crutches for RTW > 78 days was observed in the final model.

CONCLUSION

After ACL reconstruction, 92% of the patients fully return to work at a median time of 78 days. The significant predictors for fully RTW > 78 days are performing heavy knee-demanding work and a longer period of walking aided with crutches after ACL reconstruction.

Measurement and Variation in Estimation of Quality of Life Effects of Patients Undergoing Treatment for Papillary Thyroid Carcinoma

BACKGROUND

Thyroid cancer incidence is increasing. The effect of diagnosis and treatment on health-related quality of life (HRQoL) is an essential variable in the absence of a change in life span for the majority of patients. HRQoL instruments, with data useful for between-disease comparisons, are being increasingly used for health policy and outcomes evaluation. Variation exits among the instruments based on the impact of a specific disease. We assessed which of four well-validated, preference-based surveys detect changes in health and clinical intervention in patients diagnosed with papillary thyroid cancer (PTC).

METHODS

Four commonly used HRQoL questionnaires (Short Form-12v2® [SF6D], EuroQol-5D [EQ5D], and Health Utilities Index Mark 2 and 3 [HUI2, HUI3]) were administered to patients with the diagnosis of PTC at three perioperative time points during the first year of treatment. Clinicopathological and treatment course data were assessed for HRQoL impact including complications from surgery, re-operation for persistence/early recurrence, and adjuvant radioactive iodine treatment. We compared standard metrics, including ceiling effect, intraclass correlation coefficient, effect sizes, and quality-adjusted life-years between the four instruments.

RESULTS

Of 117 patients, 27% had a preoperative diagnosis of anxiety or depression, 41% had regional lymph node metastases, three had distant metastases and 49% underwent adjuvant radioactive iodine treatment. The ceiling effect (i.e., proportion with a perfect score) was greatest with EQ5D and least with SF6D. Index scores ranged from 0.77 (SF6D) to 0.90 (EQ5D). All scores declined at two weeks postoperatively and returned to pretreatment levels at six months. The SF6D was the only instrument to exceed the conventional minimally important difference between all three time points. Quality-adjusted life-years were as follows: SF6D, 0.79; EQ5D, 0.90; HUI2, 0.88; and HUI3, 0.86.

CONCLUSIONS

Our results reflect the general good health of PTC patients. The effect on quality of life is primarily related to emotional and social impacts of treatment. The results support the measurement of a similar underlying construct, although variation in detecting changes in health exists between the instruments. Of the instruments assessed, the SF6D is the most responsive to treatment effects and should be utilized in future economic analyses in this patient population.

Changes in physical activity among coronary and hypertensive patients: A longitudinal study using the Health Action Process Approach

OBJECTIVES

Physical activity (PA) is a key factor in cardiovascular disease prevention. Through the Health Action Process Approach (HAPA), the present study investigated the process of change in PA in coronary patients (CPs) and hypertensive patients (HPs).

DESIGN

Longitudinal survey study with two follow-up assessments at 6 and 12 months on 188 CPs and 169 HPs.

MAIN OUTCOME MEASURES

Intensity and frequency of PA.

RESULTS

A multi-sample analysis indicated the equivalence of almost all the HAPA social cognitive patterns for both patient populations. A latent growth curve model showed strong interrelations among intercepts and slopes of PA, planning and maintenance self-efficacy, but change in planning was not associated with change in PA. Moreover, increase in PA was associated with the value of planning and maintenance self-efficacy reached at the last follow-up Conclusions: These findings shed light on mechanisms often neglected by the HAPA literature, suggesting reciprocal relationships between PA and its predictors that could define a plausible virtuous circle within the HAPA volitional phase. Moreover, the HAPA social cognitive patterns are essentially identical for patients who had a coronary event (i.e. CPs) and individuals who are at high risk for a coronary event (i.e. HPs).

Do Gender-Predominant Primary Health Care Organizations Have an Impact on Patient Experience of Care, Use of Services, and Unmet Needs?

Physicians’ gender can have an impact on many aspects of patient experience of care. Organization processes through which the influence of gender is exerted have not been fully explored. The aim of this article is to compare primary health care (PHC) organizations in which female or male doctors are predominant regarding organization and patient characteristics, and to assess their influence on experience of care, preventive care delivery, use of services, and unmet needs. In 2010, we conducted surveys of a population stratified sample (N = 9180) and of all PHC organizations (N = 606) in 2 regions of the province of Québec, Canada. Patient and organization variables were entered sequentially into multilevel regression analyses to measure the impact of gender predominance. Female-predominant organizations had younger doctors and nurses with more expanded role; they collaborated more with other PHC practices, used more tools for prevention, and allotted more time to patient visits. However, doctors spent fewer hours a week at the practice in female-predominant organizations. Patients of these organizations reported lower accessibility. Conversely, they reported better comprehensiveness, responsiveness, counseling, and screening, but these effects were mainly attributable to doctors’ younger age. Their reporting unmet needs and emergency department attendance tended to decrease when controlling for patient and organization variables other than doctors’ age. Except for accessibility, female-predominant PHC organizations are comparable with their male counterparts. Mean age of doctors was an important confounding variable that mitigated differences, whereas other organization variables enhanced them. These findings deserve consideration to better understand and assess the impacts of the growing number of female-predominant PHC organizations on the health care system.

Effects of a Mindful Rational Living Intervention on the Experience of Destructive Emotions

The objective of this study was to measure the effects of a 90-day mindful rational living (MRL) program on the experience of destructive emotions-anger, anxiety, depression, guilt-among a normal population in a pilot trial. The MRL program combines mindfulness meditation techniques with rational emotive behavior therapy (REBT) strategies. Participants were 17 adults who completed the MRL program. Participants completed pre- and post-intervention assessments, which included scales measuring anger, anxiety, depression, guilt, rumination, shame, and subjective happiness. As hypothesized, participants showed significant decreases in anger, rumination, anxiety, depression, and shame after participating in the MRL program. There were no significant increases in subjective happiness. Findings from this pilot study provide preliminary support for the potential utility of interventions that combine mindfulness meditation with REBT strategies and can be used as the basis of future studies.

Rationale, Procedures, and Response Rates for the 2015 Administration of NCI's Health Information National Trends Survey: HINTS-FDA 2015

The National Cancer Institute (NCI) developed the Health Information National Trends Survey (HINTS) to monitor population trends in cancer communication practices, information preferences, health risk behaviors, attitudes, and cancer knowledge. The U.S. Food and Drug Administration (FDA) recognized HINTS as a unique data resource for informing its health communication endeavors and partnered with NCI to field HINTS-FDA 2015. HINTS-FDA 2015 was a self-administered paper instrument sent by mail May 29 to September 8, 2015, using a random probability-based sample of U.S. postal addresses stratified by county-level smoking rates, with an oversampling of high and medium-high smoking strata to increase the yield of current smokers responding to the survey. The response rate for HINTS-FDA 2015 was 33% (N = 3,738). The yield of current smokers (n = 495) was lower than expected, but the sampling strategy achieved the goal of obtaining more former smokers (n = 1,132). Public-use HINTS-FDA 2015 data and supporting documentation have been available for download and secondary data analyses since June 2016 at http://hints.cancer.gov . NCI and FDA encourage the use of HINTS-FDA for health communication research and practice related to tobacco-related communications, public knowledge, and behaviors as well as beliefs and actions related to medical products and dietary supplements.