Biomedical subjects

Marilyn G Klug

Publications and source records attributed to Marilyn G Klug.

16 recordsLinked to original sources

PubMed2006

A staged screening strategy for prenatal alcohol exposure and maternal risk stratification.

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

Alcohol Drinking↗

PubMed2005

Tourette Syndrome and learning disabilities.

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

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Meeting the health care needs of a rural Hispanic migrant population with diabetes.

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

Diabetes Mellitus↗

PubMed2003

Impact of smoking on cancer stage at diagnosis.

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

Adolescent↗

PubMed2003

Clinical trial of a prevention and treatment protocol for skin breakdown in two nursing homes.

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

Adult↗

PubMed2003

Children and adolescents with attention deficit-hyperactivity disorder: 1. Prevalence and cost of care.

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

Adolescent↗

PubMed2003

The attention-deficit hyperactivity disorder paradox: 2. Phenotypic variability in prevalence and cost of comorbidity.

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

Attention Deficit Disorder with Hyperactivity↗

PubMed2002

Prospective long-term follow-up of patients with pervasive developmental disorders.

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

Adult↗

PubMedDate not supplied

A school-based screening program for fetal alcohol syndrome.

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

Child↗

PubMedDate not supplied

Fetal alcohol syndrome prevention: annual and cumulative cost savings.

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

Adolescent↗

PubMedDate not supplied

Fetal alcohol syndrome: neuropsychiatric phenomics.

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

Adolescent↗

PubMedDate not supplied

Diagnosis of FAS: a comparison of the Fetal Alcohol Syndrome Diagnostic Checklist and the Institute of Medicine Criteria for Fetal Alcohol Syndrome.

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

Diagnosis, Differential↗

PubMedDate not supplied

Body mass index in fetal alcohol syndrome.

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

Age Factors↗

PubMedDate not supplied

A comparison of the effects of parental risk markers on pre- and perinatal variables in multiple patient cohorts with fetal alcohol syndrome, autism, Tourette syndrome, and sudden infant death syndrome: an enviromic analysis.

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

Age Factors↗

PubMedDate not supplied

Prenatal alcohol exposure assessment: multiple embedded measures in a prenatal questionnaire.

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

Adolescent↗

PubMedDate not supplied

Infant mortality reviews in the Aberdeen Area of the Indian Health Service: strategies and outcomes.

OBJECTIVE: To determine cause and manner of death for consecutive infant deaths in the Aberdeen Area of the Indian Health Service (AAIHS) from 1998 to 2002 and to identify risk markers for infant mortality. METHODS: Infant deaths in the AAIHS were identified from four data sources: death certificates from the four states in the AAIHS, deaths reported by local IHS Service Units, from obituaries in local and regional newspapers, and deaths reported by area hospitals. Each infant death is then sent to the local IHS service unit for review, where data from the infant and mother's chart is extracted and recorded. Local community factors, birth and death certificates, and autopsy reports are collected. The case is then reviewed at the Perinatal Infant Mortality Review (PIMR) meeting and a cause and manner of death is assigned. Summary data for the cohort was examined and then compared by mortality category and three age-at-death groups. RESULTS: Sudden infant death syndrome accounted for 33% of all infant deaths in the AAIHS. Prematurity was the second most prevalent cause-specific mortality category, accounting for 22% of all infant deaths. The authors found that infant mortality was surprisingly recurrent, with 32% of mothers of this infant having had a previous infant death. CONCLUSIONS: The PIMR committee requires substantial resources to support a review committee with appropriate expertise and their travel. Participation of local IHS staff and tribal members provides an important cultural and community perspective for the review process. Quality improvement changes are currently being implemented. These include increasing data on substance use, mental health needs, and reviews of fetal deaths. The process of mortality review has been very helpful in public education in the AAIHS.

Cause of Death↗