Bipolar disorders (BD) are characterized by symptoms of grandiosity, decreased need for sleep, pressure to keep talking, flight of ideas, distractibility, increased goal-directed activities, psychomotor agitation, and excessive involvement in pleasurable activities. Those with a bipolar disorder have a high degree of psychiatric comorbidity including substance use disorders, and they also experience increased mortality. Despite the widespread recognition of BD as an important psychiatric condition, available population-based estimates for BD prevalence differs across data sources. Cannabis is one of the most widely-used illicit substances. Evidence supports it as a risk factor for psychotic symptoms and disorders. Because populations with psychotic disorders and populations with bipolar disorder share genetic characteristics, cannabis may increase risk for bipolar disorders through the same pathways as it does with psychotic disorders. Limited and conflicting evidence regarding the association of cannabis use and bipolar disorder is currently available. This dissertation investigates cannabis use as a risk factor for incident manic symptoms and bipolar disorders in a large nationally representative longitudinal cohort. The first aim of this dissertation is to evaluate the implications for manic, hypomanic and major depressive episode prevalence estimates arising from the different approaches to assessing DSM-IV criterion between two national surveys. Differences in the assessment of impairment strongly influence manic or hypomanic classification within the NESARC. Compared to multiple imputation estimates (19.7% [95% CI: 19.3-20.1]) which treat depressed mood and anhedonia as separate symptoms, symptom assessment in the NESARC substantially underestimates major depressive episode prevalence (16.9% [95% CI: 16.1-17.6]). The second research objective examined self-reported cannabis use as a risk factor for incident manic symptoms, bipolar spectrum disorders (including manic and hypomanic episodes) and SCID-based recalibrated BD I and II. Cannabis use risk was assessed in the population as a whole and in sub-populations defined by age, substance abuse/dependence status, and family history. Among those reporting no lifetime major depressive or manic symptoms at baseline, self-reported past-year cannabis use was associated with increased odds of an incident week of extremely elevated or irritable mood accompanied by at least two manic episode criterion B symptoms (adj. OR 1.69, 95% CI: 1.08-2.65, p=.02) over the three year follow-up period. Among adults (ages 26 to 45) >=1 reported use(s) of cannabis per week was associated with incident manic or hypomanic episodes (adjusted OR 2.52, 95% CI: 1.32-4.80, p=.006). Among those endorsing no major depressive symptoms, substance abuse/dependence, or anti-social traits in their first degree relatives, past year cannabis use is associated with increased risk for incident bipolar spectrum disorders (adjusted OR 2.27, 95% CI: 1.01-5.10, p=.05) and CIDI recalibrated BD I and II (adjusted OR 5.49, 95% CI: 1.38-21.9, p=.02). Past year cannabis use risk for DSM-IV manic or hypomanic episodes among those aged 26 to 45 is concentrated in those with a baseline history of a substance use disorder (adj. OR 2.00, 95% CI: 1.10-3.66, p=.02) as compared to those with no such history (adj. OR 1.87, 95% CI: 0.49-7.21, p=.36). The third research objective of this dissertation was a sensitivity analysis using externally-predicted categorized exposures and continuous cannabis use propensities. The sensitivity analysis found evidence of exposure misclassification. Exposures defined by external propensity scores had improved cross-sectional association with bipolar spectrum disorders compared to reported use when both were compared to an external standard. No significant risk estimates were found for categorized predicted cannabis use among groups that were previously found to have significant risk from reported exposure. However, among adults 18 to 45 years of age with no manic or major depressive symptoms at baseline, past year cannabis use propensity (as a log transformed continuous measure) was associated with incident manic or hypomanic episodes (adj. OR 1.49, 95% CI: 1.10-2.03, p=.01). Elevated risk for high cannabis use propensity (>=1 use/week in the past year) was also found in this same group (adj. OR 1.33, 95% CI: 1.03-1.72, p=.03). Among those with no reported history of depression, substance abuse/dependence, or anti-social traits among their first-degree relatives, propensity for past year cannabis use (adj. OR 1.61, 95% CI: 1.11-2.32, p=.01) and propensity for >=1 use/week of cannabis in the past year (adj. OR 1.38, 95% CI: 1.03-1.85, p=.03) were associated with incident manic or hypomanic episodes. Among those without a substance use history at baseline, propensity for past year cannabis use (adj. OR 1.63, 95% CI: 1.33-1.55, p=1 use/week of cannabis in the past year (adj. OR 1.54, 95% CI: 1.26-1.88, p The findings of the first aim support the conclusion that the AUDADIS substantially under-estimated lifetime major depressive episode prevalence compared to an imputed estimate that treated anhedonia and depressed mood as separate and concurrent MDE symptoms. The operationalization of impairment for manic disorders in both the AUDADIS and CIDI strongly influences case identification, with the CIDI having suppressed manic and hypomanic prevalence estimates. Evidence was found supporting the conclusion that self-reported cannabis use is a significant risk factor for incident bipolar spectrum outcomes within subpopulations in a nationally representative cohort. A sensitivity analysis finds evidence that supports the conclusion that increasing cannabis use propensity is associated with increased risk of bipolar spectrum outcomes within population subgroups, with the greatest increased risk among those with the lowest innate risk. Under-reporting of illicit substance use is a major limitation in this dissertation; further study is needed with improved exposure measures.

Background: Opioids are often used in nursing homes to manage non-malignant pain, but little is known about their long-term use, initiation, and comparative safety. Methods: We used the Minimum Data Set 3.0 from 2011-2013 merged to Medicare and facility characteristics data to study opioid use and safety among older, long-stay residents. The specific aims were to examine the 1) prevalence of long-term opioid use; 2) geographic variation in the initiation of commonly used opioids (oxycodone, hydrocodone, tramadol); and 3) comparative safety of commonly used opioids and fracture hospitalizations. Results: One in seven long-stay residents were prescribed opioids long-term. There was extensive geographic variation in the initiation of commonly used opioids, with oxycodone (9.4%) initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varying most extensively across the United States, with the majority of variation in prescribing explained by state of residence. Compared to hydrocodone initiators (7.9 fracture hospitalizations per 100-person years), those initiating tramadol had lower rates of fracture hospitalizations (subdistribution hazard ratio [HRSD] = 0.67, 95% Confidence Interval [CI]: 0.56-0.80), whereas oxycodone initiators had similar rates of fracture hospitalizations (HRSD=1.08, 95% CI: 0.79-1.48). Conclusion: The prevalence of long-term opioid use was twice as common in nursing homes as community settings, with initiation patterns varying extensively by region and being strongly driven by state of residence. Although initiating tramadol was associated with lower rates of fractures than hydrocodone, questions on opioid risks and benefits remain and are especially pertinent given the high mortality rates in this population.

Background: Sepsis, a leading cause of US deaths, is associated with high mortality, although advances in early recognition and treatment have increased survivorship. Many aspects of sepsis pathophysiology and epidemiology have not been fully elucidated; the heterogeneous nature of infections that lead to sepsis has made fully characterizing the underlying epidemiology challenging. Methods: The University HealthSystem Consortium (UHC) from 2011-2014 and the Cerner HealthFacts® database from 2008-2014 were used. We examined associations between infection source and in-hospital mortality in the UHC dataset, stratified by age and presenting sepsis stage. We examined recent temporal trends in present-on-admission (POA) sepsis diagnoses and mortality and predictors of 30-day sepsis readmissions following sepsis hospitalizations using the HealthFacts® dataset. Results: Patients with sepsis due to genitourinary or skin, soft tissue, or bone sources had lower mortality than patients with sepsis due to respiratory sources regardless of age or presenting sepsis stage. Overall diagnoses of sepsis increased from 2008-2014; however, POA diagnoses and case fatality rates decreased. Factors that predicted re-hospitalization for sepsis included discharge to hospice, admission from or discharge to a skilled nursing facility, and abdominal infection. Conclusion: Further investigation will reveal more detail to explain the impact of infection source on in-hospital sepsis mortality for all age groups and sepsis stages. Decreasing mortality rates for all POA sepsis stages and all age groups suggest current approaches to sepsis management are having broad impact. Sepsis survivors are at significant risk for re-hospitalization; further studies are needed to understand the post discharge risks and needs of survivors.

Although evidence is currently available for population-based genetic screening and testing of individuals and their family members for certain hereditary chronic disease conditions (Tier 1), few states have integrated these genomic applications into chronic disease prevention programs. State and territorial chronic disease directors (CDDs) could provide the leadership needed to deliver these applications in more states. The purpose of this study was to determine whether an association exists between current chronic disease genomics funding or specific state genomic activities and the level of knowledge and interests in genomics by these directors. Rogers's diffusion of innovations (DIT) theory was used to explain the current climate of state chronic disease genomics and the need for an innovation champion to promote these evidence-based applications both in and out of the state health departments. A nonexperimental, cross-sectional, correlational survey of CDDs (N = 58) was performed using the Chronic Disease Director's Survey and results were analyzed using chi-square, independent t test, ANOVA, logistic regression, and Pearson's correlation coefficient. Results showed CDDs knowledge of genomics is unrelated to current state funding; however, CDD knowledge and interest in genomics was associated with inclusion of genetics in cancer control and cardiovascular health action plans, Tier 1 condition education, privacy and nondiscrimination laws, Behavioral Risk Factor Surveillance System (BRFSS) genomics questions, and frequent collaborations with outside entities. These results provide clear ideas to increase CDDs knowledge and interest in chronic disease genomics and potentially impact Tier 1 genomics implementation in more states.

Background: Loss experiences such as the loss of a spouse, a close relative or significant others become more likely in old age and may be strongly related to specific unmet health care needs. These unmet needs may often remain undetected and undertreated followed by a negative impact on well-being and social role functioning. The present study aims at exploring the relationship between loss experiences and specific unmet care needs in old age. Methods: As part of the study „Need assessment in the oldest old: application, psychometric examination and establishment of the German version of the Camberwell Assessment of Need for the Elderly (CANE)”, the adapted German version of the CANE was used in a population-representative telephone survey in a sample of 988 individuals aged 75+ years. Loss experiences within the last 12 months were assessed within the structured telephone survey. Descriptive and interferential statistical analyses were run in order to examine the association between loss experiences and occurring unmet care needs. Results: Overall, 29.7% of the oldest old reported at least one social loss with other relatives losses being the most frequent (12.5%), followed by non-family losses (10.7%). A significant relationship between loss experiences and a higher number of unmet care needs was observed, especially for close family losses. Other risk factors for unmet care needs were age, marital status, depression, social support and morbidity. Conclusions: This study provides, for the first time in Germany, data on the association between loss experiences and unmet needs. These findings may substantially contribute to the development of loss-specific interventions, effective treatment and health care planning for the bereaved elderly.

No description available.

In 2009, the American Recovery and Reinvestment Act was signed into law. This legislation provided for monetary rewards for those acute-care hospitals that meet "meaningful use" computerization and reporting criteria. The study used a descriptive, nonexperimental design to answer three research questions (1) What is the level of readiness to meet "meaningful use" criteria in the Tennessee Hospital Association (THA) member hospitals; (2) What is the level of readiness to meet "meaningful use" criteria in the rural THA member hospitals; and (3) Is there a difference in the readiness to meet "meaningful use" criteria between rural and urban THA member hospitals?. A survey was sent to 115 THA member hospital, with a return rate of 83% (N=95). The inclusion criteria focused on acute-care hospitals, with rehabilitation, psychiatric and long-term care hospitals falling into the exclusion criteria. The Readiness Score was determined for the total survey respondents (N=95), as well as for the rural (N=41) hospitals and urban (N=54) hospitals in the Tennessee Hospital Association member hospitals meeting the inclusion criteria. Z-scores of the readiness score were examined and indicated that there was one outlier with z>3.0. Therefore, that case was removed from the comparison in the t-test (N=94). The t-test comparison of rural and urban hospital found a significant difference at (p=.002), two tailed. To ensure that the slightly nonnormal distribution of the readiness scores did not explain the difference found with the t-test, an additional nonparametric test was also conducted. The Mann Whitney U-test showed that even with the assumption of a normal distribution is not made, the difference in readiness between urban and rural hospitals is still statistically significant at p=0.026.

The purpose of the study was to determine if the health parameters of female employees would improve, as measured in the posttest data, following the completion of a 12-week employee wellness program. The participants included 17 female employees from the Carter County Health Department located in Elizabethton, Tennessee. The principle investigator assessed the changes in the pretests and posttests and analyzed the data using SPSS. The results showed on average an increase in fruit and vegetable consumption and in the number of days exercised per week as well as improved diastolic blood pressure and triglyceride levels. The employees who experienced weight loss, consumed at least four servings of fruit and vegetables per day, and exercised at least 30 minutes five or more days per week had the greatest improvement in health parameters.

No description available.

On behalf of the Appalachia Funders Network (AFN), with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago conducted a study to analyze the current burden of obesity and chronic disease in central Appalachia and identify promising practices and strategies that are having a positive impact on the reduction of obesity in the region. Central Appalachia consists of parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. Regional recommendations to reduce childhood obesity and improve the overall population’s health were developed based on a review of current literature, a survey, and focus groups with both community groups and funders.