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Stineman M.G.,Center for Clinical Epidemiology and Biostatistics | Streim J.E.,University of Pennsylvania
PM and R | Year: 2010

The current biomedical and psychosocial frameworks that form the conceptual basis of medicine today are insufficient to address the needs of the medically complex and environmentally challenged populations of patients often cared for by physical medicine and rehabilitation specialists. The expanded biopsycho-ecological model of health, illness, injury, and disability operating through mechanisms of Health Environmental Integration (HEI) encourages a more complete understanding of illness, injury, activity limitation, and participation restriction as arising at the interface between the person and the environment. HEI recognizes complex interacting multilevel functional hierarchies beginning at the cellular level and ending at the individual's experience of the environment. Although the foci of illness and injury are within the body and mind, the physical and social environments contain elements that can cause or exacerbate disease and barriers that interact in ways that lead to injuries and disabilities. Furthermore, these environments hold the elements from which treating agents, facilitators, and social supports must be fashioned. The highly integrative biopsycho-ecological framework provides an expanded basis for understanding the objective causes and subjective meanings of disabilities. Disabilities are reduced through HEI by seeking to maximally integrate the body and mind (the self) with both the surrounding physical environment and other people in society. HEI offers mechanisms for interdisciplinary research, an expanded framework for education and empowerment, and a blueprint for optimizing day-to-day clinical care at both the individual patient and treatment population levels in the ever-changing scientific, political, and policy environments. © 2010 American Academy of Physical Medicine and Rehabilitation. Source


Quill C.M.,University of Rochester | Quill C.M.,Leonard Davis Institute Center for Health Incentives and Behavioral Economics | Ratcliffe S.J.,Center for Clinical Epidemiology and Biostatistics | Harhay M.O.,Leonard Davis Institute Center for Health Incentives and Behavioral Economics | And 4 more authors.
Chest | Year: 2014

BACKGROUND: The magnitude and implication of variation in end-of-life decision-making among ICUs in the United States is unknown.METHODS: We reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. We used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU.RESULTS: Patient factors associated with increased odds of DFLST included advanced age female sex, white race, and poor baseline functional status (all P < .001). However, associations with several of these factors varied among ICUs (eg, black race had an OR for DFLST from 0.18 to 2.55 across ICUs). The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with an increased odds of a DFLST (OR = 1.19). The predicted probability of DFLST varied approximately sixfold among ICUs aft er adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs ( r = 0.53, 0.41-0.68).CONCLUSION: Although patient factors explain much of the variability in DFLST practices significant effects of ICU culture and practice influence end-of-life decision-making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure. © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Source


News Article
Site: http://www.rdmag.com/rss-feeds/all/rss.xml/all

While early antibiotic use has been associated with a number of rare long-term health consequences, new research links antibiotics to one of the most important and growing public health problems worldwide -- obesity. A study1 published online in Gastroenterology, the official journal of the American Gastroenterological Association, found that administration of three or more courses of antibiotics before children reach an age of 2 years is associated with an increased risk of early childhood obesity. "Antibiotics have been used to promote weight gain in livestock for several decades, and our research confirms that antibiotics have the same effect in humans," said Frank Irving Scott, MD, MSCE, assistant professor of medicine at University of Colorado Anschutz Medical Campus, Aurora, and adjunct scholar, Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania, Philadelphia. "Our results do not imply that antibiotics should not be used when necessary, but rather encourage both physicians and parents to think twice about antibiotic usage in infants in the absence of well-established indications." The researchers performed a large population-representative cohort study in the United Kingdom to assess the association between antibiotic exposure before age 2 years and obesity at age 4 years. Children with antibiotic exposure had a 1.2 percent absolute and 25 percent relative increase in the risk of early childhood obesity. Risk is strongest when considering repeat exposures to antibiotics, particularly with three or more courses. "Our work supports the theory that antibiotics may progressively alter the composition and function of the gut microbiome, thereby predisposing children to obesity as is seen in livestock and animal models," added Dr. Scott. Antibiotics are prescribed during an estimated 49 million pediatric outpatient visits per year in the U.S. A large portion of these prescriptions (more than 10 million annually) are written for children without clear indication, despite increased awareness of the societal risks of antibiotic resistance, as well as other tangible risks, including dermatologic, allergic and infectious complications; inflammatory bowel disease; and autoimmune conditions. Further research is required to assess whether these findings remain into adolescence and young adulthood, as well as to determine if early antibiotic usage leads to later-onset obesity. Research should also examine whether specific classes of antibiotics are more strongly associated with subsequent obesity. The American Gastroenterological Association, through its Center for Gut Microbiome Research and Education, will continue to promote and share research related to antibiotics and obesity, and their relation to the gut microbiome. To speak with a member of the center's strategic advisory board, contact media@gastro.org.


Stineman M.G.,Center for Clinical Epidemiology and Biostatistics
Topics in Stroke Rehabilitation | Year: 2011

Effective stroke rehabilitation and the reduction of disability demand the best of biomedical sciences, but that science must be framed within a more holistic perspective that recognizes the essential nature and uniqueness of lived experiences as they occur within physical and cultural places. The traditional biomedical and the dominant biopsychosocial frameworks of disease are not suffi cient to characterize the causes and meaning of disability. The biopsycho-ecological framework is offered as a necessary expansion of the biomedical and biopsychosocial models of illness to guide disability research, to frame rehabilitation care, and to enrich disability studies. Two research projects are presented to illustrate the importance of and synergies between measurable and subjective aspects of science. The fi rst example, as a comparative effectiveness study, has the potential to justify alternative patterns of rehabilitation services through quantifi able evidence. The second example, as a clinical tool for empowerment, has the potential to make those services more personally meaningful through the analysis of patients' preferences and life worlds. The combination of qualitative with quantitative scientifi c methods can yield a deeper understanding of disability and rehabilitation practices than either type of approach alone. © 2011 Thomas Land Publishers, Inc.. Source


Schussler-Fiorenza Rose S.M.,Spinal USA | Xie D.,University of Pennsylvania | Stineman M.,University of Pennsylvania | Stineman M.,Center for Clinical Epidemiology and Biostatistics
PM and R | Year: 2014

Objective: To assess relationships between adverse childhood experiences and self-reported disabilities in adult life. Design: Cross-sectional, random-digit-dialed, state-population-based survey (Behavioral Risk Factor Surveillance System). Setting: Fourteen states and the District of Columbia. Participants: Noninstitutionalized adults ages≥18 years surveyed in 2009 and/or in 2010 (n= 81,184). Methods: The Behavioral Risk Factor Surveillance System Adverse Childhood Experience (ACE) Module asks about abuse (physical, sexual, emotional), family dysfunction (exposures to domestic violence, living with mentally ill, substance abusing, or incarcerated family member(s), and/or parental separation and/or divorce) that occurred before age 18years. The ACE score sums affirmed ACE categories (range, 0-8). We controlled for demographic characteristics (age, race, education, income, and marital status) and self-reported physical health conditions (stroke, myocardial infarction, diabetes, coronary heart disease, asthma). Five states asked participants about mental health conditions (anxiety, depression). A subset analysis of participants in these states evaluated the effect of adjusting for these conditions. Main Outcome Measurements: The primary outcome was disability (self-reported activity limitation and/or assistive device use). Results: More than half of participants (57%) reported at least 1 adverse childhood experience category, and 23.2% reported disability. The odds ratio (95% confidence interval) of disability increased in a graded fashion from odds ratio 1.3 (95% confidence interval, 1.2-1.4) among those who experienced 1 adverse experience to odds ratio 5.8 (95% confidence interval, 4.6-7.5) among those with 7-8 adverse experiences compared with those with no such experiences when adjusting for demographic factors. The relationship between adverse experiences and disability remained strong after adjusting for physical and mental health conditions. Conclusions: There is a strong graded relationship between childhood exposure to abuse and household dysfunction and self-reported disability in adulthood, even after adjusting for potentially mediating health conditions. Greater clinician, researcher, and policymaker awareness of the impact of childhood adversity on disability is crucial to help those affected by childhood adversity lead more functional lives. © 2014 American Academy of Physical Medicine and Rehabilitation. Source

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