Wellness in Nursing Education to Promote Resilience and Reduce Burnout: Protocol for a Holistic Multidimensional Wellness Intervention and Longitudinal Research Study Design in Nursing Education.

BACKGROUND: The United States faces a nursing shortage driven by a burnout epidemic among nurses and nursing students. Nursing students are an integral population to fuel the nursing workforce at high risk of burnout and increased rates of perceived stress. OBJECTIVE: The aim of this paper is to describe WellNurse, a holistic, interdisciplinary, multidimensional longitudinal research study that examines evidence-based interventions intended to reduce burnout and increase resilience among graduate and undergraduate nursing students. METHODS: Graduate and undergraduate nursing students matriculated at a large public university in the northeastern United States are eligible to enroll in this ongoing, longitudinal cohort study beginning in March 2021. Participants complete a battery of health measurements twice each semester during the fourth week and the week before final examinations. The measures include the Perceived Stress Scale, the Satisfaction with Life Scale, the Oldenburg Burnout Inventory, the Brief Resilience Scale, and the Pittsburgh Sleep Quality Index. Participants are eligible to enroll in a variety of interventions, including mindfulness-based stress reduction, mindful eating, fitness training, and massage therapy. Those who enroll in specific, targeted interventions complete additional measures designed to target the aim of the intervention. All participants receive a free Fitbit device. Additional environmental changes are being implemented to further promote a culture that supports academic well-being, including recruiting a diverse student population through evidence-based holistic admissions, inclusive teaching design, targeted resilience and stress reduction workshops, and cultural shifts within classrooms and curricula. The study design protocol is registered at Open Science Framework (DOI 10.17605/OSF.IO/NCBPE). RESULTS: The project was funded on January 1, 2022. Data collection started in March 2022. A total of 267 participants have been recruited. Results will be published after each semester starting in December 2023. WellNurse evaluation follows the Rapid Cycle Quality Improvement framework to continuously monitor ongoing project processes, activity outcomes, and progress toward reducing burnout and increasing resilience. Rapid Cycle Quality Improvement promotes the ability to alter WellNurse interventions, examine multiple interventions, and test their effectiveness among the nursing education population to identify the most effective interventions. CONCLUSIONS: Academic nursing organizations must address student burnout risk and increase resilience to produce a future workforce that provides high-quality patient care to a diverse population. Findings from WellNurse will support evidence-based implementations for public baccalaureate and master's nursing programs in the United States. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49020.

Peripartum and Postpartum Analgesia and Pain in Women Prescribed Buprenorphine for Opioid Use Disorder Who Deliver by Cesarean Section.

Aim: Little is known about whether pain can be effectively managed in pregnant women with opioid use disorder (OUD) during delivery hospitalization, particularly those undergoing surgery and taking buprenorphine as medication for OUD (MOUD). To address this question, we compared pain scores and opioid analgesic utilization during delivery hospitalization in women taking their pre-hospital dose of buprenorphine who delivered by cesarean section to matched controls. To inform future research efforts, we also began to explore opioid analgesic utilization and pain scores by type of anesthesia as this variable is often not included in related literature. Methods: Retrospective matched cohort study of 46 women prescribed buprenorphine during pregnancy who delivered by cesarean section during a 7-year period. Results: When compared to matched controls, women taking their pre-hospital dose of buprenorphine undergoing cesarean section utilized more opioid analgesics as measured by morphine milligram equivalents (MME) (mean MME first 48 hours 153.0 mg vs 175.1 mg, respectively, P < .01) but had similar pain scores during delivery hospitalization. There was no difference in MME utilization by maternal dose of buprenorphine though sample sizes were small. Women on buprenorphine who received spinal anesthesia with morphine had mean pain scores that were 1.4 points lower (P = .01) during the first 48 hours than women on buprenorphine receiving other methods of anesthesia. Discussion And Conclusions: Pregnant women taking their pre-hospital dose of buprenorphine throughout their surgical delivery hospitalization were able to achieve pain relief similar to women not on MOUD but had higher MME requirements. Our results add to the emerging body of evidence suggesting that individuals on MOUD can achieve adequate post-surgical pain management without adjusting their pre-hospital dose of buprenorphine. Further research is required to fully understand the optimal buprenorphine dosing regimen during surgical hospitalizations. Our results also provide important preliminary evidence that spinal anesthesia containing opioids can be used effectively in individuals with OUD requiring surgical intervention.

Mapping the time course of semantic activation in mediated false memory: Immediate classification, naming, and recognition.

We evaluated the time course of persistent automatic spreading activation from a mediated list of indirect associates (e.g., meow, day, and basement) that all converged upon a non-presented critical item (CI; e.g., black). Mediated lists were related to CIs through non-presented mediators (e.g., cat, night, and bottom). Three speeded tasks were used to evaluate the time course of semantic activation of the CI: a continuous semantic classification task (concrete/abstract decisions), a naming task (reading words aloud), or a recognition test (old/new memory decisions). Test lists were presented immediately following the mediated lists, and CIs were presented in the first, third, or eighth positions. The results revealed that in both the classification and naming tasks, CI priming was greatest in the first test position and declined across the remaining test positions. Importantly, priming was statistically reliable in the late test positions, providing evidence for long-term semantic priming (i.e., across positions on immediate tasks). False recognition, however, was stable across test positions. Collectively, these patterns suggest that spreading-activation processes decline, consistent with implicit spreading activation, and these processes may contribute to long-term false recognition.

Assessing Older Adult Wellness: An Assessment of the Psychometric Properties of the Lifestyle Survey.

BACKGROUND AND PURPOSE: To measure wellness interventions, researchers need valid and reliable tools to measure the concept of wellness. The purpose of this study is to examine the validity and reliability of the Lifestyle Survey instrument. METHODS: Community-dwelling older adults were recruited and asked to evaluate the reliability by engaging in a test retest reliability. Observer agreement was measured by calculating a kappa score for each item. Content validity was evaluated with a focus group session. RESULTS: (n = 56) older adults completed the survey on time one and time two. Of 115 items, 77.39% demonstrated moderate or higher kappa agreement. Focus group respondents identified rewording a few items. CONCLUSION: With refinement, the Lifestyle Survey is a valid and reliable measure of wellness among community-dwelling older adults.

Linear mixed-effects models for estimation of pulmonary metastasis growth rate: implications for CT surveillance in patients with sarcoma.

OBJECTIVES: Sarcoma patients often undergo surveillance chest CT for detection of pulmonary metastases. No data exist on the optimal surveillance interval for chest CT. The aim of this study was to estimate pulmonary metastasis growth rate in sarcoma patients. METHODS: This was a retrospective review of 95 patients with pulmonary metastases (43 patients with histologically confirmed metastases and 52 with clinically diagnosed metastases) from sarcoma treated at an academic tertiary-care center between 01 January 2000 and 01 June 2019. Age, sex, primary tumor size, grade, subtype, size and volume of the pulmonary metastasis over successive chest CT scans were recorded. Two metastases per patient were chosen if possible. Multivariate linear mixed-effects models with random effects for each pulmonary metastasis and each patient were used to estimate pulmonary metastasis growth rate, evaluating the impact of patient age, tumor size, tumor grade, chemotherapy and tumor subtype. We estimated the pulmonary metastasis volume doubling time using these analyses. RESULTS: Maximal primary tumor size at diagnosis (LRT statistic = 2.58, df = 2, p = 0.275), tumor grade (LRT statistic = 1.13, df = 2, p = 0.567), tumor type (LRT statistic = 7.59, df = 6, p = 0.269), and patient age at diagnosis (LRT statistic = 0.735, df = 2, p = 0.736) were not statistically significant predictors of pulmonary nodule growth from baseline values. Chemotherapy decreased the rate of pulmonary nodule growth from baseline (LRT statistic = 7.96, df = 2, p = 0.0187). 95% of untreated pulmonary metastases are expected to grow less than 6 mm in 6.4 months. There was significant intrapatient and interpatient variation in pulmonary metastasis growth rate. Pulmonary metastasis volume growth rate was best fit with an exponential model in time. The volume doubling time for pulmonary metastases assuming an exponential model in time was 143 days (95% CI (104, 231) days). CONCLUSIONS: Assuming a 2 mm nodule is the smallest reliably detectable nodule by CT, the data suggest that an untreated pulmonary metastasis is expected to grow to 8 mm in 8.4 months (95% CI (4.9, 10.2) months). Tumor size, grade and sarcoma subtype did not significantly alter pulmonary metastasis growth rate. However, chemotherapy slowed the pulmonary metastasis growth rate. ADVANCES IN KNOWLEDGE: CT surveillance intervals for pulmonary metastases can be estimated based on metastasis growth rate. There was significant variation in the pulmonary metastasis growth rate between metastases within patient and between patients. Pulmonary nodule volume growth followed an exponential model, linear in time.

Digital Food and Beverage Marketing Environments in a National Sample of Middle Schools: Implications for Policy and Practice.

BACKGROUND: One promising approach to influence nutrition behavior is to limit food and beverage marketing to children. Children are a lucrative market and schools may be an effective setting in which to intervene. Studies have shown that marketing in schools is prevalent but little is known about digital marketing (DM) to students in the school setting. METHODS: We used an online survey to assess DM environments in a national sample of middle schools. RESULTS: Our findings demonstrate that students are exposed to marketing through school devices. Gaps in school district, school and classroom policy and practice lead to student exposure to food and beverage marketing. CONCLUSIONS: Our data point to actionable policy and practice change at the school district, individual school, and classroom levels that could help limit unwanted and harmful food and beverage marketing to youth.

Predictors of treatment retention in postpartum women prescribed buprenorphine during pregnancy.

AIM: To determine variables related to treatment retention in women six and twelve months postpartum that were in medication treatment using buprenorphine during pregnancy. METHODS: This retrospective cohort study of 190 maternal-infant dyads exposed to buprenorphine during pregnancy examines rates of treatment retention at six and twelve months postpartum and also analyzes a variety of potential predictors of treatment retention including illicit drug use in the third trimester, delayed entry into medication treatment and co-occurring mental health diagnoses requiring prescription medication. RESULTS: At 12months postpartum, women appeared more likely to remain in medication treatment if they entered treatment early in pregnancy (defined as either being in treatment at the time of conception, p=0.001, or entering medication treatment prior to 13weeks gestation, p=0.037). Being prescribed an antidepressant medication during the third trimester was also associated with enhanced treatment retention at six months postpartum (p=0.005). At both six and twelve months postpartum, the use of illicit drugs (including opioids, cocaine and benzodiazepines) during the third trimester was negatively correlated with treatment retention (p=0.012 and p<0.001, respectively). CONCLUSIONS: Early access to medication treatment is associated with treatment retention in women prescribed buprenorphine during pregnancy. This has important public health implications as access to treatment is limited in many parts of the country and many women are only able to obtain treatment after becoming pregnant. Being prescribed an antidepressant medication during pregnancy may enhance treatment retention, supporting the work of previous authors.

Maternal and infant outcomes following third trimester exposure to marijuana in opioid dependent pregnant women maintained on buprenorphine.

BACKGROUND: To determine whether maternal and infant outcomes are associated with exposure to marijuana during the third trimester in a population of opioid dependent pregnant women maintained on buprenorphine. METHODS: This retrospective cohort study of 191 maternal-infant dyads exposed to buprenorphine during pregnancy examines a variety of variables including gestational age, birthweight, method of delivery, Apgar scores at one and five minutes, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS in infants exposed to marijuana during the third trimester as compared to infants not exposed to marijuana during the third trimester. RESULTS: Analyses failed to support any significant relationship between marijuana use in the third trimester and a variety of maternal and infant outcomes. Two important variables - the likelihood of requiring pharmacologic treatment for NAS (27.6% in marijuana exposed infants vs. 15.7% in non-marijuana exposed infants, p=0.066) and the duration of infant hospital stay (7.7days in marijuana exposed infants vs. 6.6days in non-exposed infants, p=0.053) trended toward significance. CONCLUSIONS: Preliminary results indicate that marijuana exposure in the third trimester does not complicate the pregnancy or the delivery process. However, the severity of the infant withdrawal syndrome in the immediate postnatal period may be impacted by marijuana exposure. Because previous study of prenatal marijuana exposure has yielded mixed results, further analysis is needed to determine whether these findings are indeed significant.

Investigating How to Align Schools' Marketing Environments With Federal Standards for Competitive Foods.

BACKGROUND: Limiting food and beverage marketing to children is a promising approach to influence children's nutrition behavior. School-based marketing influences nutrition behavior and studies have consistently found marketing for nonnutritious foods and beverages in schools. No studies have examined the resources necessary to align school marketing environments with federal school nutrition standards. The purpose of this study was to determine how to improve school marketing environments so that they align with new federal competitive food nutrition standards. METHODS: We assessed food marketing environments in 3 Portland, Maine schools using the Food and Beverage Marketing Survey (FBMS) and provided technical assistance to bring their marketing environments into conformity with the federal competitive food regulations, tracking resources and strategies for marketing removal. RESULTS: Noncompliant marketing was significantly reduced pre- to postintervention. Intervention strategies were facilitated by the School Health Coordinator and school-based wellness teams. CONCLUSIONS: Low monetary resources were required to remove marketing not compliant with federal nutrition standards for foods sold in schools. Several key challenges remain to sustain efforts. This study provides timely information for policymakers to support crafting policies that address the realities of school nutrition environments and universal enforcement challenges.

Sustainability of key Maine Youth Overweight Collaborative improvements: a follow-up study.

BACKGROUND: Primary care is an opportune setting to contribute to obesity prevention and treatment. However, there is limited evidence for effective and sustainable interventions in primary care. The Maine Youth Overweight Collaborative (MYOC) successfully affected office systems, provider behavior, and patient experience. The current study evaluates the effect of MYOC on provider knowledge, beliefs, practices, patient experience, and office systems, in 2012, three years postintervention. METHODS: A quasi-experimental field trial was used with all seven original MYOC intervention sites that participated in MYOC between 2004 and 2009 and two non-MYOC control sites. Data from immediately post-MYOC in 2009 served as the baseline comparison. Main outcome measures included rates of recording of BMI percentile in chart, weight classification, use of the 5210 behavioral screening tool, parental reports of counseling received on 5210 topics, and clinician reports of changes in knowledge, beliefs, and practices. RESULTS: Many key MYOC improvements were sustained or improved 3 years postintervention and demonstrated improvements, as compared to control sites. CONCLUSION: In an environment where obesity has become a priority for healthcare providers and systems, we demonstrate sustainable improvements in clinical decision support and family management of risk behaviors within a primary-care-based approach to addressing overweight risk among children and youth. Some declines were observed for more-complex behavioral and system outcomes. Many opportunities for office system and provider improvements remain.

Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy.

INTRODUCTION: Although a growing body of evidence suggests that buprenorphine is a safe alternative to methadone in the treatment of opioid-dependent pregnant women, little is known about breastfeeding in this population. The first objective of this study was to describe breastfeeding rates among opioid-dependent pregnant women maintained on buprenorphine in an integrated medical and behavioral health program. The second objective was to determine whether breastfeeding is related to the duration, severity, and frequency of pharmacologic treatment for neonatal abstinence syndrome (NAS). METHODS: A retrospective chart review was conducted for all infants born to opioid-dependent pregnant women treated in the integrated buprenorphine program between December 2007 and August 2012. RESULTS: Eighty-five maternal-infant pairs were identified. Sixty-five women (76%) chose to breastfeed their infants after birth; of the women who initiated breastfeeding in the hospital, 66% were still breastfeeding 6 to 8 weeks postpartum. Although the data suggest that infants who were breastfed had less severe NAS (mean peak NAS, 8.83 vs 9.65 on a modified Finnegan Scoring System) and were less likely to require pharmacologic treatment (23.1% vs 30.0%) than infants who were not breastfed, these results were not statistically significant. DISCUSSION: More than three-quarters of the opioid-dependent pregnant women in this case series chose to breastfeed after birth. Although a direct comparison of care models is not possible, the integrated model of care potentially reduced some of the barriers to breastfeeding as the women accessed all their care in a single, infant-friendly setting. Further work is needed to definitively determine whether breastfeeding mitigates NAS.

Motor stereotypies and volumetric brain alterations in children with Autistic Disorder.

Motor stereotypies are defined as patterned, repetitive, purposeless movements. These stigmatizing motor behaviors represent one manifestation of the third core criterion for an Autistic Disorder (AD) diagnosis, and are becoming viewed as potential early markers of autism. Moreover, motor stereotypies might be a tangible expression of the underlying neurobiology of this neurodevelopmental disorder. In this study, we videoscored stereotypies recorded during semi-structured play sessions from school age children with AD. We examined the effect of severity and persistence over time of stereotypies on brain volumetric changes. Our findings confirmed that the brain volume of school age children with AD is, on average, larger than that of age-matched typically developing children. However, we have failed to detect any sign of volumetric differences in brain regions thought to be particularly linked to the pathophysiology of stereotypies. This negative finding may suggest that, at least with respect to motor stereotypies, functional rather than structural alterations might be the underpinning of these disruptive motor manifestations of autism.

Statistical adjustments for brain size in volumetric neuroimaging studies: some practical implications in methods.

Volumetric magnetic resonance imaging (MRI) brain data provide a valuable tool for detecting structural differences associated with various neurological and psychiatric disorders. Analysis of such data, however, is not always straightforward, and complications can arise when trying to determine which brain structures are "smaller" or "larger" in light of the high degree of individual variability across the population. Several statistical methods for adjusting for individual differences in overall cranial or brain size have been used in the literature, but critical differences exist between them. Using agreement among those methods as an indication of stronger support of a hypothesis is dangerous given that each requires a different set of assumptions be met. Here we examine the theoretical underpinnings of three of these adjustment methods (proportion, residual, and analysis of covariance) and apply them to a volumetric MRI data set. These three methods used for adjusting for brain size are specific cases of a generalized approach which we propose as a recommended modeling strategy. We assess the level of agreement among methods and provide graphical tools to assist researchers in determining how they differ in the types of relationships they can unmask, and provide a useful method by which researchers may tease out important relationships in volumetric MRI data. We conclude with the recommended procedure involving the use of graphical analyses to help uncover potential relationships the ROI volumes may have with head size and give a generalized modeling strategy by which researchers can make such adjustments that include as special cases the three commonly employed methods mentioned above.

Location of food stores near schools does not predict the weight status of Maine high school students.

OBJECTIVE: To examine the relationship between stores selling calorie-dense food near schools and student obesity risk, with the hypothesis that high availability predicts increased risk. METHODS: Mail surveys determined height, weight, and calorie-dense food consumption for 552 students at 11 Maine high schools. Driving distance from all food stores within 2 km (1.24 miles) of schools (or the closest store) was computed, and the impact of food store density and proximity to schools on student body mass index was determined by logistic regression. RESULTS: Ten schools had ≥ 1 store selling soda, and 8 schools had ≥1 fast-food restaurant within 1 km (0.62 miles). There were no significant relationships between the proximity or density of food stores around schools and student obesity risk. Students obtained sugar-sweetened beverages in many locations including at school. CONCLUSIONS AND IMPLICATIONS: Unhealthful food choices are ubiquitous. Consequently, stores selling these food items near schools have no significant affect on student obesity.

Impact of Maine's statewide nutrition policy on high school food environments.

INTRODUCTION: We assessed the effect on the food environments of public high schools of Maine's statewide nutrition policy (Chapter 51), which banned "foods of minimal nutritional value" (FMNV) in public high schools that participated in federally funded meal programs. We documented allowable exceptions to the policy and describe the school food environments. METHODS: We mailed surveys to 89 high school food-service directors to assess availability pre-Chapter 51 and post-Chapter 51 of soda, other sugar-sweetened beverages, and junk food. Frequency data were tabulated pre-Chapter 51 and post-Chapter 51, and Fisher exact test was used to assess significance in changes. We conducted food and beverage inventories at 11 high schools. RESULTS: The survey return rate was 61% (N = 54). Availability of soda in student vending significantly decreased pre-Chapter 51 versus post-Chapter 51 (P = .04). No significant changes were found for other sugar-sweetened beverages and junk food. Exceptions to Chapter 51 were permitted to staff (67%), to the public (86%), and in career and technical education programs (31%). Inventories in a subset of schools found no availability of soda for students, whereas other sugar-sweetened beverages and junk food were widely available in à la carte, vending machines, and school stores. Candy, considered a FMNV, was freely available. Soda advertisement on school grounds was common. CONCLUSION: Student vending choices improved after the implementation of Chapter 51; however, use of FMNV as the policy standard may be limiting, as availability of other sugar-sweetened beverages and junk food was pervasive. School environments were not necessarily supportive of the policy, as advertisement of soda was common and some FMNV were available. Furthermore, local exceptions to Chapter 51 likely reduced the overall effect of the policy.

Impact of a school health coordinator intervention on health-related school policies and student behavior.

BACKGROUND: Health-related, school-based interventions may serve to prevent disease and improve academic performance. The Healthy Maine Partnerships (HMP) initiative funded local school health coordinators (SHCs) as a part of Maine's Coordinated School Health Program (CSHP) beginning in January 2001. SHCs established school health leadership teams and implemented annual work plans to address health risk behaviors. This study evaluates the impact of the Healthy Maine Partnerships SHC (HMPSHC) intervention on school policies and student risk behaviors after its first 5 years. METHODS: Data sources include the Maine School Health Profiles Survey and the Maine Youth Drug and Alcohol Use Survey/Youth Tobacco Survey. Cross-sectional analyses were performed on 2006 data to assess physical activity, nutrition, and tobacco-related policy associations with the HMPSHC intervention. Finally, policy and student behavior analyses were conducted to assess associations. RESULTS: Intervention schools were more likely to be associated with physical activity intramural offerings, improved nutritional offerings, and tobacco cessation programs. In intervention schools, supportive school policies were associated with decreased soda consumption, decreased inactivity, and decreased tobacco use. Required school health education curricula were more predictive of decreased risk behavior in intervention schools than in nonintervention schools. CONCLUSIONS: In schools with SHCs, there exists a stronger association with improved school programs. Improved policies and programs were associated with decreases in risk behavior among students in intervention schools. The HMPSHC intervention may be a viable CSHP model to replicate and evaluate in other settings.

Hypothalamic abnormalities in schizophrenia: sex effects and genetic vulnerability.

BACKGROUND: This is a unique hypothalamic magnetic resonance imaging (MRI) study in schizophrenia, an important region in the limbic system. We hypothesized abnormal volumetric increases, with greater severity in multiplex families (more than one ill member) compared with simplex families (one ill). We tested the hypothesis that normal hypothalamic sexual dimorphism is disrupted in schizophrenia. METHODS: Eighty-eight DSM-III-R schizophrenia cases (40 simplex and 48 multiplex), 43 first-degree nonpsychotic relatives, and 48 normal comparisons systematically were compared. A 1.5-Tesla General Electric scanner was used to acquire structural MRI scans, and contiguous 3.1-mm slices were used to segment anterior and posterior hypothalamus. General linear model for correlated data and generalized estimating equations were used to compare cases, relatives, and controls on right and left hypothalamus, controlled for age, sex, and total cerebral volume. Spearman's correlations of hypothalamic volumes with anxiety were calculated to begin to examine arousal correlates with structural abnormalities. RESULTS: Findings demonstrated significantly increased hypothalamic volume in cases and nonpsychotic relatives, particularly in regions of paraventricular and mammillary body nuclei, respectively. This increase was linear from simplex to multiplex cases, was positively correlated with anxiety, and had a greater propensity in women. CONCLUSIONS: Findings suggest important implications for understanding genetic vulnerability of schizophrenia and the high rate of endocrine abnormalities.

Maximum likelihood estimation of marginal pairwise associations with multiple source predictors.

Researchers interested in the association of a predictor with an outcome will often collect information about that predictor from more than one source. Standard multiple regression methods allow estimation of the effect of each predictor on the outcome while controlling for the remaining predictors. The resulting regression coefficient for each predictor has an interpretation that is conditional on all other predictors. In settings in which interest is in comparison of the marginal pairwise relationships between each predictor and the outcome separately (e.g., studies in psychiatry with multiple informants or comparison of the predictive values of diagnostic tests), standard regression methods are not appropriate. Instead, the generalized estimating equations (GEE) approach can be used to simultaneously estimate, and make comparisons among, the separate pairwise marginal associations. In this paper, we consider maximum likelihood (ML) estimation of these marginal relationships when the outcome is binary. ML enjoys benefits over GEE methods in that it is asymptotically efficient, can accommodate missing data that are ignorable, and allows likelihood-based inferences about the pairwise marginal relationships. We also explore the asymptotic relative efficiency of ML and GEE methods in this setting.

Move & Improve: a worksite wellness program in Maine.

BACKGROUND: We describe the evaluation process and outcomes of Move & Improve, a worksite wellness program in Maine. The evaluation process was based on the Centers for Disease Control and Prevention's Framework for Program Evaluation in Public Health and community-based participatory research principles. Innovative approaches are required to address burgeoning chronic disease trends and risk factors. Worksites are an ideal setting in which to affect working adults and high-risk individuals. Using community-based participatory research methodology increases community capacity for evaluation, dissemination, and use of evaluation results. CONTEXT: Move & Improve is an ongoing program that was implemented in 1996. Although evaluation data have been collected since the program's inception, a more systematic evaluation based on community-based participatory research principles was undertaken in 2003 and 2004 with the technical assistance of the Maine-Harvard Prevention Research Center and Colby College. METHODS: The Maine-Harvard Prevention Research Center facilitated the development of a program logic model, evaluation questions, data collection instruments, an analysis plan, presentations, and reports. We used a cross-sectional study design with nonparticipant comparison groups. CONSEQUENCES: Data indicate possible program improvement strategies and substantial improvements in lifestyle factors among participants. INTERPRETATION: Limitations of the evaluation include participant self-selection, cross-sectional study design, a lack of adequate resources for evaluation, and the challenges of using community-based participatory research methods. Despite these limitations, Move & Improve program staff consider the evaluation of the program a success and have learned ways to improve the program and future evaluation efforts. Overall satisfaction with the process has been nurtured through community-based participatory research methods. This approach also enabled us to meet key evaluation standards.

Adjustment for whole brain and cranial size in volumetric brain studies: a review of common adjustment factors and statistical methods.

In this article we address analytic challenges inherent in brain volumetrics (i.e., the study of volumes of brains and brain regions). It has sometimes been assumed in the literature that deviations in regional brain size in clinical samples are directly related to maldevelopment or pathogenesis. However, this assumption may be incorrect; such volume differences may, instead, be wholly or partly attributable to individual differences in overall dimension (e.g., for head, brain, or body size). What quantitative approaches can be used to take these factors into account? Here, we provide a review of volumetric and nonvolumetric adjustment factors. We consider three examples of common statistical methods by which one can adjust for the effects of body, head, or brain size on regional volumetric measures: the analysis of covariance, the proportion, and the residual approaches. While the nature of the adjustment will help dictate which method is most appropriate, the choice is context sensitive, guided by numerous considerations-chiefly the experimental hypotheses, but other factors as well (including characteristic features of the disorder and sample size). These issues come into play in logically framing the assessment of putative abnormalities in regional brain volumes.