Identifying Core Values with a Hierarchical, Ipsative, Preference Assessment.

Values provide a foundation for decision making, behavior, and emotional reaction; they are often used by practitioners to design effective interventions for self-awareness and personal growth. This report describes a novel, user-friendly method that identifies core values with a hierarchical ipsatization procedure (HIP) that is transparent and efficient. Response bias, validity, and user satisfaction were examined in a study in which 602 respondents completed a survey asking them to rate 80 values and use HIP to identify their 4 most inspiring and motivating values. HIP enabled selecting these 4 core values from 80 candidates in 5-7 min, with minimal evidence of response bias. The selections made during HIP were consistent with the rating data, providing evidence for HIP's concurrent validity. 88% of the respondents felt the 4 values identified by HIP inspired and motivated them more than any other values they could think of. These findings suggest HIP is a useful tool for identifying core values, especially in applied settings.

Helping parents choose treatments for young children with autism: A comparison of applied behavior analysis and eclectic treatments.

BACKGROUND: Nurse practitioners (NPs) increasingly meet with families of young children who have been recently diagnosed with autism spectrum disorder (ASD). These families face a bewildering variety of treatment options and can benefit from working with NPs who can help them better understand those options and the likely outcomes for their children. PURPOSE: This study describes outcomes for young children with autism, who were treated with either applied behavior analysis (ABA) or eclectic treatment. Nurse practitioners can use this information to help families choose treatments for their children. METHODS: Children diagnosed with autism received ABA (n = 50) or eclectic treatment (n = 32). Age-appropriate assessments in a variety of domains were made before and after up to 7 years of treatment. RESULTS: Initial scores were below normal in every domain except motor skills. Sixty percent of children had normal cognitive scores after ABA, compared with only 25% of children after eclectic treatment. Other domains also showed better outcomes after ABA than eclectic treatment. IMPLICATIONS FOR PRACTICE: Nurse practitioners should be prepared to help families understand treatment options and their likely outcomes. The present study suggests that young children diagnosed with ASD can achieve normal levels of functioning in a variety of domains. These outcomes are much more likely after ABA than eclectic treatment.

Comparison of behavior analytic and eclectic early interventions for young children with autism after three years.

In a previous study, we compared the effects of just over one year of intensive behavior analytic intervention (IBT) provided to 29 young children diagnosed with autism with two eclectic (i.e., mixed-method) interventions (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005). One eclectic intervention (autism programming; AP) was designed specifically for children with autism and was intensive in that it was delivered for an average of 25-30 h per week (n = 16). The other eclectic intervention (generic programming; GP) was delivered to 16 children with a variety of diagnoses and needs for an average of 15-17 h per week. This paper reports outcomes for children in all three groups after two additional years of intervention. With few exceptions, the benefits of IBT documented in our first study were sustained throughout Years 2 and 3. At their final assessment, children who received IBT were more than twice as likely to score in the normal range on measures of cognitive, language, and adaptive functioning than were children who received either form of eclectic intervention. Significantly more children in the IBT group than in the other two groups had IQ, language, and adaptive behavior test scores that increased by at least one standard deviation from intake to final assessment. Although the largest improvements for children in the IBT group generally occurred during Year 1, many children in that group whose scores were below the normal range after the first year of intervention attained scores in the normal range of functioning with one or two years of additional intervention. In contrast, children in the two eclectic treatment groups were unlikely to attain scores in the normal range after the first year of intervention, and many of those who had scores in the normal range in the first year fell out of the normal range in subsequent years. There were no consistent differences in outcomes at Years 2 and 3 between the two groups who received eclectic interventions. These results provide further evidence that intensive behavior analytic intervention delivered at an early age is more likely to produce substantial improvements in young children with autism than common eclectic interventions, even when the latter are intensive.

Stopping menopausal hormone therapy: if breast cancer really decreased, why did colorectal cancer not increase?

OBJECTIVE: The Women's Health Initiative (WHI) study of postmenopausal hormone therapy (HT) found that estrogen plus progestogen therapy (EPT) decreased colorectal cancer risk. Thus, the decline in EPT use from 2002 to 2003 should have precipitated an increase in the incidence of colorectal cancer. We tested this prediction using the SEER 9 epidemiologic database. METHODS: We analyzed WHI data concerning the effects of EPT and estrogen therapy (ET) on colorectal cancer risks. We also examined HT prescription sales data, as well as SEER 9 colorectal cancer incidences from 2001 to 2004. RESULTS: In the WHI study, the incidence of colorectal cancer was comparable in EPT placebo-users, ET users, and ET placebo-users, but significantly lower in EPT users. Assuming that 30% of eligible women used HT in 2001, the decline in EPT sales from 2002 to 2003 of 63% should have increased the incidence of colorectal cancer by 2.8% in the overall population at risk. However, the SEER 9 colorectal cancer incidence fell by 5.9% in this population, which is comparable to the 6.7% decrease observed for invasive breast cancer from 2002 to 2003. CONCLUSIONS: Declining EPT use from 2002 to 2003 should have precipitated an increase in the incidence of colorectal cancer, but the opposite trend was seen in the SEER 9 database during this time. The incidences of invasive breast cancer and colorectal cancer both declined by a similar amount from 2002 to 2003, despite the results of the WHI study predicting opposing trends for the two different types of cancer. Thus, the SEER 9 findings are fundamentally incompatible with expectations from the WHI findings. This implies that reductions in HT use from 2002 to 2003 cannot account for the contemporaneous changes in invasive breast cancer and colorectal cancer incidences. Alternative explanations must be found.

The breast cancer "plunge" after initial publication of the WHI results: an alternative explanation.

From 2002 to 2003, the breast cancer incidence in the United States, as reported by the National Cancer Institute's Surveillance Epidemiology and End Results (SEER 9) database, appeared to decrease by 6.7%. This phenomenon has been attributed to a reduction in the use of menopausal hormone therapies after the initial publication of the Women's Health Initiative (WHI) study results in July of 2002. However, attempts to draw a causal association between the use of menopausal hormone therapies and the incidence of breast cancer have not accounted for the facts that prescriptions of estrogen-plus-progestin menopausal therapies, which are associated with increased rates of breast cancer, fell by 53% from 2002 to 2003, while prescriptions of estrogen-only therapies fell by only 27%. To address this issue, we analyzed the effects of the higher rate of discontinuation of estrogen-plus-progestin menopausal therapies relative to estrogen-only treatments during the 2002-2003 time period, based upon the effects of different types of menopausal hormone therapies on breast cancer incidence as determined by the WHI interventional hormone trials. This approach demonstrates that the relative persistence with menopausal estrogen-only therapies - as compared to estrogen-plus-progestin therapies - can explain the reduction in breast cancer incidence from 2002 to 2003. In addition, we point out the incompatibility of the breast cancer incidence rates found in the two WHI interventional hormone trials and the rates reported in the SEER 9 database. Based on these findings, we conclude - as previously demonstrated in the estrogen-only arm of the WHI interventional hormone trials - that menopausal estrogen-only use is not responsible for increasing the risk of breast cancer in menopausal women and may, in fact, be protective. Additional studies are still needed to better define the relationship between different types of menopausal hormone therapies and the incidence of breast cancer.

A computerized method for accurately predicting fetal macrosomia up to 11 weeks before delivery.

OBJECTIVE: To improve the prediction of birth weight and fetal macrosomia by combining sonographically derived fetal biometric data with routinely recorded pregnancy-specific information. STUDY DESIGN: Retrospective data were obtained for 218 normal gravidas who had obstetrical ultrasonography performed within 11 weeks of delivery. Multiple regression was employed to derive a set of equations for predicting birth weight that used different combinations of ultrasonographic and pregnancy-specific variables. RESULTS: A set of 38 unique combination equations was derived to accurately predict birth weight up to 11 weeks before delivery. The equations use different combinations of ultrasonographic and pregnancy-specific variables, so that predictions are still possible in the face of missing data. When ultrasonographic measurements are taken within 3 weeks of delivery, fetal macrosomia is predicted with 75% sensitivity, 93% specificity, and 67% and 95% positive and negative predictive value, respectively. The equations are equally as accurate for primiparous and multiparous women from all racial groups. A jackknifing procedure was used to validate the predictive accuracy of the equations for use with new subjects. CONCLUSION: The combined approach of predicting fetal macrosomia using ultrasonographic fetal measurements and pregnancy-specific characteristics is superior to pre-existing approaches that rely on either method alone. The method can be used up to 11 weeks before delivery, allowing fetal macrosomia to be predicted reliably in low-risk populations sufficiently early for prospective clinical intervention to be undertaken.

A comparison of intensive behavior analytic and eclectic treatments for young children with autism.

We compared the effects of three treatment approaches on preschool-age children with autism spectrum disorders. Twenty-nine children received intensive behavior analytic intervention (IBT; 1:1 adult:child ratio, 25-40 h per week). A comparison group (n=16) received intensive "eclectic" intervention (a combination of methods, 1:1 or 1:2 ratio, 30 h per week) in public special education classrooms (designated the AP group). A second comparison group (GP) comprised 16 children in non-intensive public early intervention programs (a combination of methods, small groups, 15 h per week). Independent examiners administered standardized tests of cognitive, language, and adaptive skills to children in all three groups at intake and about 14 months after treatment began. The groups were similar on key variables at intake. At follow-up, the IBT group had higher mean standard scores in all skill domains than the AP and GP groups. The differences were statistically significant for all domains except motor skills. There were no statistically significant differences between the mean scores of the AP and GP groups. Learning rates at follow-up were also substantially higher for children in the IBT group than for either of the other two groups. These findings are consistent with other research showing that IBT is considerably more efficacious than "eclectic" intervention.

Preventing ectopic pregnancies: how often does transperitoneal transmigration of sperm occur in effecting human pregnancy?

OBJECTIVE: Transperitoneal transmigration of sperm constitutes the mechanism by which ectopic pregnancies occur in unilaterally obstructed fallopian tubes. This study was undertaken to determine how often sperm transmigrate across the peritoneal cavity to effect human pregnancy. DESIGN: In women with non-communicating rudimentary uterine horn pregnancies, the ratio of total uterine horn pregnancies to prior contralateral hemi-uterine pregnancies was calculated to infer the overall transperitoneal sperm transmigration rate. The prior parity frequency distribution was also determined to calculate the best-fit per-pregnancy probability of attaining a rudimentary horn pregnancy with each subsequent gestation using maximum likelihood estimation. SETTING: 20th century. SAMPLE: Non-communicating rudimentary uterine horn pregnancies reported from 40 countries. METHODS: Two hundred and seventy-two cases were identified using manual and computerised searches of Index Medicus, Excerpta Medica, the Index-Catalogue of the Library of the Surgeon-General's Office and standard reference tracing. MAIN OUTCOME MEASURES: The ratio of total prior non-rudimentary uterine horn pregnancies to rudimentary uterine horn pregnancies and the frequency distribution of prior maternal parities. RESULTS: Prior to the incident 272 uterine horn pregnancies, the number of observed pregnancies was 292 (ratio = 0.93), implying an aggregate sperm transmigration rate of 0.48. Using the prior parity frequency distribution, the best-fit probability of attaining a rudimentary horn gestation per-pregnancy was 0.51 (95% CI 0.48-0.56). CONCLUSIONS: Intraperitoneal sperm transmigration occurs approximately half the time in effecting spontaneous human pregnancies. To minimise the risk of ectopic tubal pregnancy in woman with unilaterally damaged fallopian tubes, salpingectomy should be the preferred surgical treatment, rather than attempting tubal salvage and repair.

Hemoglobin, altitude and birth weight: does maternal anemia during pregnancy influence fetal growth?

OBJECTIVE: To investigate the relationship between maternal hemoglobin concentration, altitude and birth weight. STUDY DESIGN: Birth weights in 235 term pregnancies were investigated for their dependence on maternal hemoglobin concentration after other maternal and pregnancy-specific influences on fetal weight were taken into account. The additional predictive value of hemoglobin concentration on birth weight was assessed using multiple regression. Using published data, the relationship of hemoglobin concentration to altitude was determined, as was the effect of increasing altitude on birth weight. The quantitative effect of hemoglobin concentration on birth weight was correlated with the effect of altitude on hemoglobin concentration to assess whether this could account for the known decrease in birth weight with increasing altitude. RESULTS: Birth weights ranged from 2,220 to 4,850 g (mean, 3,505+/-443), and hemoglobin concentrations ranged from 9.3 to 13.5 g/dL (mean, 11.6+/-0.8). Apart from other known predictive variables, the variation in maternal hemoglobin concentrations at constant altitude independently explained 2.6% of the variance in birth weight (r=-.18, P=.003). Term birth weight was reduced by 89 g for each 1.0 g/dL increase in hemoglobin concentration (P<.01). For every 1,000-m increase in altitude, hemoglobin concentration increased by 1.52 g/dL and birth weight decreased by 117 g. CONCLUSION: Birth weight correlates negatively with maternal hemoglobin concentration. This is consistent with the well-known effect of high-altitude exposure during pregnancy, which increases both hematocrit and blood viscosity and lowers birth weight. The quantitative effect on birth weight of increasing maternal hemoglobin concentration at constant altitude is within 13% of the change in birth weight that can be attributed to the change in hemoglobin concentration associated with increases in altitude.

Prediction of term birth weight in Hispanic women using an equation based on maternal characteristics.

OBJECTIVE: To test the accuracy of a birth weight prediction equation based on maternal characteristics in Hispanic women. STUDY DESIGN: A previously published birth weight prediction equation based on maternal and pregnancy-specific characteristics was used to predict birth weights for 283 normal Caucasian women of Hispanic ethnicity. The accuracy of these birth weight estimates was compared to a similarly selected group of 233 non-Hispanic Caucasian gravidas who were located 2500 miles away. RESULTS: Birth weight predictions for Hispanic women were accurate to within +/- 8.4% (+/- 287 g). The percentages of birth weights predicted to within +/- 15 and +/- 10% of actual values were 84 and 68%, respectively. These results were no different than those that were obtained for non-Hispanic Caucasian gravidas. CONCLUSIONS: A previously derived birth weight prediction equation based on maternal and pregnancy-specific characteristics alone successfully predicts term birth weight in normal Hispanic gravidas to within +/- 8.4% (+/- 287 g).

Ultrasonographic prediction of term birth weight: how accurate is it?

OBJECTIVE: The purpose of this study was to investigate the accuracy of 25 ultrasonic algorithms for the estimation of term fetal weight and to compare these results to an equation that is based on maternal and pregnancy-specific characteristics alone. STUDY DESIGN: Ultrasonography was performed in 82 nondiabetic gravid women at 35 to 41 weeks of gestation. Fetal biparietal diameter, abdominal circumference, head circumference, and femur length were measured. Twenty-five ultrasonic fetal biometric algorithms and an equation that is based only on maternal characteristics were used to predict birth weight. RESULTS: The correlation between predicted and actual birth weight ranged from 0.44 to 0.79 for the ultrasonic algorithms and was 0.60 for the maternal characteristics equation. Ultrasonic algorithms had mean absolute prediction errors that ranged from +/-263 to 646 g (+/-7.5%-18.8%). Accuracy for the maternal characteristics equation was not statistically different from the best performing ultrasonic algorithms (+/-353 g, +/-10.4%). CONCLUSION: Term birth weight estimates that use ultrasonography are generally no more accurate than predictions that are based solely on quantitative assessment of maternal and pregnancy-specific characteristics.

Relationship of paternal factors to birth weight.

OBJECTIVE: To investigate the relationship between paternal characteristics and birth weight. STUDY DESIGN: A total of 241 gravidas with uncomplicated, singleton, term pregnancies were studied. Maternal demographic and pregnancy-specific characteristics were used to calculate the expected birth weight for each fetus using a previously validated birth weight prediction equation. The additional independent predictive value of 4 paternal variables was assessed using multiple regression. RESULTS: Before adjustment for other variables, paternal height and weight significantly correlated with birth weight, but paternal age and body mass index did not. After controlling for maternal and pregnancy-specific factors that are known to influence fetal weight, only paternal height was significant as a predictive variable. The proportion of variance in birth weight that could be independently explained by paternal height was 2%. A 10-g gain in fetal weight was associated with each centimeter of increase in paternal height (P < .02). Using the resulting combination equation that included paternal height as a variable, 31% of the variance in term birth weight could be explained, and birth weights could be accurately predicted to within +/- 8.3% (+/- 288 g). Fathers with heights 2 SD above and below the mean had the term birth weight of their offspring increased and diminished by 125 g, respectively. CONCLUSION: Paternal height explains an independent portion of the variance in term birth weight among normal newborns of up to 250 g that cannot be explained by other maternal or pregnancy-specific factors. Paternal age, weight and body mass index do not independently influence birth weight.

Validation of a birth weight prediction equation based on maternal characteristics.

OBJECTIVE: To validate the accuracy of a birth weight prediction equation based on maternal and pregnancy-specific characteristics and to assess its value in predicting fetal macrosomia. STUDY DESIGN: A previously published birth weight prediction equation based on maternal and pregnancy-specific characteristics was used to predict birth weight in 244 Caucasian gravidas with uncomplicated, singleton, term pregnancies. Results were assessed by calculating the mean absolute error, the mean absolute percentage error and the percentage of birth weights correctly predicted to within +/- 10% and +/- 15% of actual birth weight. The sensitivity, specificity and positive and negative predictive value for predicting fetal weight > 4,000 g were calculated. RESULTS: Birth weight was accurately predicted to within an average of +/- 8.1% (+/- 280 g). The percentage of weights accurately predicted to within 15% of actual birth weight was 87%, and the percentage predicted to within +/- 10% was 68%. The sensitivity for predicting fetal weight > 4,000 g was 52%, specificity 90%, positive predictive value 42% and negative predictive value 93%. The area under the receiver operating characteristic curve for predicting fetal macrosomia was 0.83. CONCLUSION: An equation using maternal and pregnancy-specific characteristics can predict term birth weight in gravidas with uncomplicated singleton pregnancies to within +/- 8.1% (+/- 280 g). The accuracy of the method for predicting birth weight > 4,000 g is comparable to that obtained using ultrasonic fetal biometry.

Early-pregnancy glucose screening for gestational diabetes mellitus.

OBJECTIVE: To determine the accuracy of the 50-g, one-hour glucose screening test administered at 16 weeks of pregnancy for identifying women with gestational diabetes mellitus. STUDY DESIGN: Two hundred fifty-five women underwent 50-g, one-hour glucose screening tests at 16 weeks of pregnancy. Those with results > or = 135 mg/dL underwent 100-g, three-hour glucose tolerance tests. All patients without diagnoses of gestational diabetes during the second trimester of pregnancy underwent standard third-trimester glucose testing. RESULTS: Gestational diabetes mellitus was diagnosed in 25 patients. Glucose screening tests administered at 16 weeks of pregnancy identified 96% (24) of these patients. Patients with 16-week glucose screening test results > or = 135 mg/dL had a 55% risk of developing diabetes during pregnancy, while the risk was 0.6% for patients with 16-week test results < or = 110 mg/dL. Patients with 16-week glucose screening test results in the intermediate range, 111-134 mg/dL, had a 4.8% risk of developing diabetes during pregnancy. CONCLUSION: Glucose screening at 16 weeks of pregnancy is a useful alternative to third-trimester screening for gestational diabetes. The negative predictive value of screening test results < or = 110 mg/dL is 99.4%. The positive predictive value for screening test results > or = 135 mg/dL is 55%. This latter finding is superior to the 8.6-22% found during the third-trimester.

Correlation between one-hour, 50-g glucose screening values in successive pregnancies.

OBJECTIVE: To investigate the relationship between one-hour, 50-g oral glucose screening test results in successive pregnancies and to assess the risk of gestational diabetes in women who had a previously negative glucose screening test during a prior pregnancy. STUDY DESIGN: Sixty-nine women were studied who had successive pregnancies delivered at intervals ranging from one to four years. All had glucose screening tests performed at 24-32 weeks of gestation during both pregnancies. The relationship between glucose screening test results was examined for interpregnancy intervals of up to two, three and four years. RESULTS: The correlation for interpregnancy glucose screening test results was .60, .49 and .47 for pregnancy intervals of up to two, three and four years, respectively (P < .001). The mean glucose screening test result was 108 +/- 23 mg/dL for prior pregnancies and 104 +/- 21 mg/dL for subsequent pregnancies (no significant difference). A screening test result > or = 140 mg/dL occurred in 1.6% of cases in which a previous test result was < 140 mg/dL during a prior pregnancy. CONCLUSION: A glucose screening test result of < 140 mg/dL during pregnancy is strongly predictive of a subsequent negative screening test result in a succeeding pregnancy when it occurs within four years. Under such circumstances, the risk of gestational diabetes during a subsequent pregnancy is reduced by 85-95% to no more than 0.3%.