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In Pennsylvania on February 16, 2006, a New York City resident collapsed with rigors and was hospitalized. On February 21, the Centers for Disease Control and Prevention and the New York City Department of Health and Mental Hygiene were notified that Bacillus anthracis had been identified in the patient's blood. Although the patient's history of working with dried animal hides to make African drums indicated the likelihood of a natural exposure to aerosolized anthrax spores, bioterrorism had to be ruled out first. Ultimately, this case proved to be the first case of naturally occurring inhalational anthrax in 30 years. This article describes the epidemiologic and environmental investigation to identify other cases and persons at risk and to determine the source of exposure and scope of contamination. Because stricter regulation of the importation of animal hides from areas where anthrax is enzootic is difficult, public healthcare officials should consider the possibility of future naturally occurring anthrax cases caused by contaminated hides. Federal protocols are needed to assist in the local response, which should be tempered by our growing understanding of the epidemiology of naturally acquired anthrax. These protocols should include recommended methods for reliable and efficient environmental sample collection and laboratory testing, and environmental risk assessments and remediation.

The detection of polycyclic aromatic hydrocarbon (PAH)-DNA adducts in human lymphocytes may be useful as a surrogate end point for individual cancer risk prediction. In this study, we examined the relationship between environmental sources of residential PAH, as well as other potential factors that may confound their association with cancer risk, and the detection of PAH-DNA adducts in a large population-based sample of adult women. Adult female residents of Long Island, New York, aged at least 20 years were identified from the general population between August 1996 and July 1997. Among 1556 women who completed a structured questionnaire, 941 donated sufficient blood (25+ ml) to allow use of a competitive ELISA for measurement of PAH-DNA adducts in peripheral blood mononuclear cells. Ambient PAH exposure at the current residence was estimated using geographic modeling (n=796). Environmental home samples of dust (n=356) and soil (n=360) were collected on a random subset of long-term residents (15+ years). Multivariable regression was conducted to obtain the best-fitting predictive models. Three separate models were constructed based on data from : (A) the questionnaire, including a dietary history; (B) environmental home samples; and (C) geographic modeling. Women who donated blood in summer and fall had increased odds of detectable PAH-DNA adducts (OR=2.65, 95% confidence interval (CI)=1.69, 4.17; OR=1.59, 95% CI=1.08, 2.32, respectively), as did current and past smokers (OR=1.50, 95% CI=1.00, 2.24; OR=1.46, 95% CI=1.05, 2.02, respectively). There were inconsistent associations between detectable PAH-DNA adducts and other known sources of residential PAH, such as grilled and smoked foods, or a summary measure of total dietary benzo-[a]-pyrene (BaP) intake during the year prior to the interview. Detectable PAH-DNA adducts were inversely associated with increased BaP levels in dust in the home, but positively associated with BaP levels in soil outside of the home, although CIs were wide. Ambient BaP estimates from the geographic model were not associated with detectable PAH-DNA adducts. These data suggest that PAH-DNA adducts detected in a population-based sample of adult women with ambient exposure levels reflect some key residential PAH exposure sources assessed in this study, such as cigarette smoking.

To evaluate whether environmental tobacco smoke (ETS) influences breast cancer incidence, data from a population-based case-control study were analyzed. Respondents with available ETS information assessed by in-person questionnaires included 1356 newly diagnosed cases and 1383 controls. Relative to nonsmokers who reported no residential ETS exposure throughout the life course, the odds ratios (OR) for breast cancer were not substantially elevated in relation to ETS exposure, active smoking, or a joint measure of active and passive smoking (OR, 1.15, 95% CI, 0.90, 1.48). An increased OR, however, was noted among nonsmokers who lived with a smoking spouse for over 27 years (2.10, 95% CI, 1.47, 3.02), although no dose-response was evident. Also, among women with hormone-receptor-positive tumors only, the OR for both active and passive smoking was increased (1.42 for ER+ PR+, 95% CI, 1.00, 2.00). Our data suggest that if there is an effect for ETS on breast cancer, that effect is restricted to selected subgroups of women, such as those with long-term exposure from a smoking spouse.

This paper presents the results of a small sample simulation study designed to evaluate the performance of a recently proposed test statistic for the analysis of correlated binary data. The new statistic is an adjusted Mantel-Haenszel test, which may be used in testing for association between a binary exposure and a binary outcome of interest across several fourfold tables when the data have been collected under a cluster sampling design. Al- though originally developed for the analysis of periodontal data, the proposed method may be applied to clustered binary data arising in a variety of settings, including longitu- dinal studies, family studies, and school-based research. The features of the simulation are intended to mimic those of a research study of periodontal health, in which a large number of observations is made on each of a relatively small number of patients. The simulation reveals that the adjusted test statistic performs well in finite samples, having empirical type I error rates close to no...

A common clinical conception of alcohol dependence is that it is chronic, and the idea of impaired control figures prominently in an influential definition of alcohol dependence. We investigated the meaning of a diagnosis of DSM-IV alcohol dependence in untreated individuals.Household residents screened for elevated drinking were assessed for DSM-IV alcohol dependence and re-interviewed 1 year later. We report on 115 subjects with and 460 subjects without current DSM-IV alcohol dependence at baseline. Follow-up drinking indicators included a measure of sustained reduction in drinking.No support was found for a lower probability of sustained reduction in drinking at follow-up among the group with baseline DSM-IV alcohol dependence. Significant group differences indicated that the dependent group was more likely to reduce drinking.A diagnosis of DSM-IV alcohol dependence among untreated individuals implies a prognosis that is different from that for the same diagnosis among those seen in treatment settings. This does not necessarily indicate that the diagnosis is invalid, but rather suggests that risk factors for chronic course are more applicable to cases of DSM-IV alcohol dependence seen in treatment settings.

The clinical and research importance of tolerance and/or withdrawal in the diagnosis of substance dependence has been identified as a key area needing clarification. Earlier longitudinal studies did not identify whether diagnoses of alcohol dependence were current or lifetime. In this study, the prognostic significance of the DSM-IV physiological specifier was investigated among cases of alcohol dependence current at the baseline interview. The role of tremors, required in DSM-III and DSM-III-R, was investigated as well.Household residents (N = 130; 57% men) meeting full criteria for current DSM-IV alcohol dependence in a baseline interview were re-interviewed a year later and DSM-IV alcohol dependence was again evaluated. Reliable structured interviews were used to make the diagnoses. The DSM-IV physiologic specifier and its components were tested as predictors of outcome of DSM-IV alcohol dependence, and included an additional definition of alcohol withdrawal that required tremors. Chi-square tests and adjusted odds ratios indicated statistical significance of group differences on outcome.The DSM-IV physiological specifier (tolerance or withdrawal) did not predict 1-year chronicity of DSM-IV alcohol dependence, nor did tolerance when considered separately. However, withdrawal predicted poor outcome (e.g., 1-year chronicity of DSM-IV alcohol dependence). The effect of withdrawal was strengthened when tremors were required as part of the withdrawal syndrome.In contrast to earlier longitudinal research, this study supports the prognostic relevance of one component of the present DSM-IV physiological specifier--withdrawal. Withdrawal appears to have stronger prognostic meaning when the DSM-III-R version, in which tremors were required, is used. Further studies of the physiological subtype may benefit from studying subjects who have been clearly identified at the baseline evaluation as having a current diagnosis of dependence.

Little is known about the effects of contextual factors on the chronicity of alcohol dependence in the general population. Many adults in the United States live with others in a wide range of relationships. The drinking of household members was investigated as a potential risk factor for persistence of DSM-IV alcohol dependence in a prospective study of household residents.At-risk drinking (five or more drinks on at least one occasion) in adult household members living with respondents was assessed at the time of the baseline interview for the index subjects in the study (N = 128; 56% men) who lived with other adults and who met DSM-IV criteria for current alcohol dependence. Index subjects' drinking and demographic variables were also measured at baseline. Approximately 1 year later, follow-up interviews determined the status of alcohol dependence in the 128 subjects.Alcohol dependence was significantly more likely to be persistent among subjects with at-risk drinking among household members.The presence of other adult heavy drinkers in a household increased the risk of persistence of alcohol dependence in this community sample. Considerably more remains to be learned about the relationship and its treatment implications.

Prior research in a community sample indicated that almost half the individuals receiving a diagnosis of DSM-IV alcohol abuse did so on the basis of only one symptom, driving after drinking too much. While this is certainly unwise behavior, it may not be a psychiatric disorder. Therefore, we investigated the differential validity of this subgroup of abuse cases by testing the association of a set of external validating criterion variables with three groups: those who met criteria for abuse just for drinking-driving, those who met criteria by other means and those with no alcohol diagnosis. Present status of past cases of abuse was also investigated.Subjects were 22,204 U.S. household residents (a subset of a national probability sample) interviewed in 1992 with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. The generalized logit model was the principal means of analysis.Subjects who met criteria for DSM-IV alcohol abuse just for drinking-driving differed from subjects with no diagnosis on about half the variables tested, while those who met criteria for abuse in other ways differed from subjects with no diagnosis on all variables tested. The two abuse groups differed from each other on some but not all variables. Past cases of abuse for drinking-driving and past cases of other abuse were equally likely to have remitted in the last 12 months, and slightly less likely to meet criteria for current dependence.Further conceptual and empirical work is needed to resolve the difficulties with the DSM-IV alcohol abuse category.

Although a category for alcohol abuse has been included in the major nomenclatures since DSM-III, many questions have been raised about the definitions and validity of this category.We investigated DSM-IV alcohol abuse in 628 at-risk drinkers residing in households who never met criteria for DSM-IV alcohol dependence at the time of a baseline interview. Cross-sectional and prospective longitudinal information were used.Subjects most often met criteria for abuse with the single criterion, recurrent hazardous use (usually driving after drinking too much, on average 4.5 times per year). Younger and white subjects were more likely to receive the abuse diagnosis at baseline, as were drug users and those who drank five or more drinks per occasion frequently. Very few subjects received a diagnosis of DSM-IV alcohol dependence at follow-up, and those who did were equally likely to come from the abuse and non-abuse baseline groups. A current abuse diagnosis at baseline strongly and significantly predicted an abuse diagnosis at follow-up, although a past-only (remitted) abuse diagnosis at baseline was not clearly predictive of abuse at follow-up.The DSM-IV alcohol abuse category has some predictive validity. However, given the manner in which respondents met criteria for the disorder, its merits as a diagnostic category remain in question. Researchers should be cautious about combining alcohol dependence and abuse into the same category.

The alcohol dependence syndrome was initially presented as a condition with graded severity. However, to receive a diagnosis that is categorical, a diagnostic threshold must be determined. Much previous research on this issue has focused on setting a threshold that will produce the highest possible consistency in rates between one set of diagnostic criteria and the next. It is possible that a different threshold may be more valid. Results from a community sample supported a minimum diagnostic threshold of three or more dependence symptoms but the sample was not nationally representative. Therefore, we investigated the meaning of the 'orphan' status (one or two dependence symptoms but no DSM-IV alcohol dependence diagnosis) in a large national sample. Two sets of analyses were performed, the first using a current timeframe and the second using a lifetime timeframe. Abstainers were excluded from all analyses. In each set of analyses, three groups were compared: subjects with no symptoms of any alcohol use disorder; diagnostic 'orphans' with one or two symptoms of dependence; and subjects who met full criteria for DSM-IV alcohol dependence. Several variables significantly differentiated the three groups, including heavy drinking and family history of alcoholism. Group differences were reduced among 'orphans' and subjects with no symptoms who had at least one occasion of drinking five or more drinks in the year prior to the interview. The results provide support for the decision to require a minimum of three symptoms to make a diagnosis of alcohol dependence, for scientific as well as pragmatic reasons.

To receive a DSM-IV diagnosis of alcohol dependence, an individual must manifest at least three out of seven possible dependence criteria. Thus, individuals may manifest one or two dependence criteria yet not receive the dependence diagnosis. In a sense, these latter individuals may be seen as diagnostic `orphans', since they have individual symptoms of dependence but no diagnoses. A study of these individuals sheds light on the validity of the three-symptom severity threshold for a diagnosis of DSM-IV alcohol dependence. Thus, we investigated the meaning of the `orphan' status through cross-sectional and longitudinal research in a general population sample. Three groups were compared at baseline, subjects with no symptoms of any alcohol use disorder (148), diagnostic `orphans' with one or two symptoms of dependence (136) and subjects who met full criteria for DSM-IV alcohol dependence (140). Several variables significantly differentiated the three groups, including binge drinking and family history of alcoholism. At a 1-year follow-up point, very few of the `orphans' met criteria for DSM-IV alcohol dependence. The proportion of new onsets from the `orphan' group and the group with no symptoms did not differ significantly. Binge drinking predicted chronicity of `orphan' status, but family history of alcoholism did not. The results support the decision to require a minimum of three symptoms to make a diagnosis of alcohol dependence.

Objectives. We investigated whether foreign birthplace and residence were associated with an increased risk of childhood lead poisoning. Methods. We conducted a matched case–control study among New York City children (mean age=3 years) tested for lead poisoning in 2002 (n=203 pairs). Children were matched on age, date of test, and residential area. Blood lead and housing data were supplemented by a telephone survey administered to parents or guardians. Conditional logistic regression analysis was used to examine the relationship of lead poisoning status to foreign birthplace and time elapsed since most recent foreign residence after adjustment for housing and behavioral risk factors. Results. Both foreign birthplace and time since most recent foreign residence had strong adjusted associations with lead poisoning status, with children who had lived in a foreign country less than 6 months before their blood test showing a particularly elevated risk of lead poisoning relative to US-born children with no foreign residential history before their blood test (odds ratio [OR]=10.9; 95% confidence interval [CI]=3.3, 36.5). Conclusions. Our findings demonstrate an increased risk of lead poisoning among immigrant children.

It is unclear whether breast cancer risk varies by age and menopausal status in relation to use of hormonal birth control (HBC) and hormone replacement therapy (HRT), taken singly or cumulatively. The authors utilized data from 1,478 cases and 1,493 controls aged 20-98 years with known menopausal status, who had participated in a population-based, case-control study conducted on Long Island during 1996-1997. Exogenous hormone use over the lifecourse was assessed by use of memory aids. The authors examined associations among women in these subgroups: premenopausal (n = 968), postmenopausal65 years (n = 1,045), and postmenopausalor = 65 years (n = 958). Among premenopausal women, risk was increased for ever use of HBC (odds ratio (OR) = 1.37, 95% confidence interval (CI): 1.04, 1.81) or HRT (OR = 1.81, 95% CI: 1.17, 2.81) and was pronounced among women reporting use of both HBC and HRT (OR = 2.59, 95% CI: 1.50, 4.46), long-term HRT use (OR = 3.93, 95% CI: 1.43, 10.84), or estrogen-plus-progestin therapy (OR = 3.51, 95% CI: 1.45, 8.49). There was no effect of ever HBC use among postmenopausal women aged less than 65 years, but risk was modestly elevated for more than 5 years of HRT use (OR = 1.41, 95% CI: 1.00, 1.99). Among postmenopausal women aged 65 years or more, odds ratios for HBC or HRT use were around the null. These results emphasize that timing of exogenous hormone use is important. Women who used these hormones before menopause had elevated risks, but the harmful effects began to decline with age after menopause.

Polycyclic aromatic hydrocarbons (PAH) are potent mammary carcinogens in rodents, but their effect on breast cancer development in women is not clear. To examine whether currently measurable PAH damage to DNA increases breast cancer risk, a population-based case-control study was undertaken on Long Island, NY. Cases were women newly diagnosed with in situ and invasive breast cancer; controls were randomly selected women frequency matched to the age distribution of cases. Blood samples were donated by 1102 (73.0%) and 1141 (73.3%) of case and control respondents, respectively. Samples from 576 cases and 427 controls were assayed for PAH-DNA adducts using an ELISA. The geometric mean (and geometric SD) of the log-transformed levels of PAH-DNA adducts on a natural scale was slightly, but nonsignificantly, higher among cases [7.36 (7.29)] than among controls [6.21 (4.17); P = 0.51]. The age-adjusted odds ratio (OR) for breast cancer in relation to the highest quintile of adduct levels compared with the lowest was 1.51 [95% confidence interval (CI), 1.04-2.20], with little or no evidence of substantial confounding (corresponding multivariate-adjusted OR, 1.49; 95% CI, 1.00-2.21). There was no consistent elevation in risk with increasing adduct levels, nor was there a consistent association between adduct levels and two of the main sources of PAH, active or passive cigarette smoking or consumption of grilled and smoked foods. These data indicate that PAH-DNA adduct formation may influence breast cancer development, although the association does not appear to be dose dependent and may have a threshold effect.

Background: The role of positive family history in the etiology of alcohol dependence has been demonstrated repeatedly but little is known about the effect of this risk factor on the chronicity of alcohol dependence once it has begun. Methods: We studied the effects of parental and sibling history in conjunction with frequency of binge drinking in a sample of 169 community residents who met criteria for DSM-IV alcohol dependence at the baseline interview. Subjects were re-interviewed approximately 1 year later and the status of their alcohol-dependence disorders (remitted or chronic) was determined. Results: Parental history of alcoholism was significantly related to chronicity of alcohol dependence, as was frequency of binge drinking. Conclusions: Failure to find an effect for family history on chronicity would have suggested that the effect was transient, perhaps interacting with time-limited environmental vulnerability. The finding of a positive relationship between family history and chronicity suggests that the relationship between familial/genetic background and alcohol dependence is stable.

The Alcohol Dependence Syndrome concept has had a widespread influence on the major nosological classification systems, most recently with its operationalization as DSM-IV alcohol dependence. Although many studies have provided evidence of the validity of the Alcohol Dependence Syndrome in clinical samples, little validation work has been conducted in general population samples on DSM-IV alcohol dependence or the distinction of DSM-IV alcohol dependence from DSM-IV alcohol abuse. We therefore examined the cross-sectional validity of DSM-IV alcohol dependence and abuse in 27,616 household residents who participated in a 1992 national survey on alcohol use disorders. Validity was investigated by testing the association of a set of five "criterion" variables, external to the alcohol diagnostic criteria, with dependence and abuse diagnoses. Results indicated that dependence diagnoses were significantly associated with all criterion variables when compared with those with no diagnosis and also when compared with alcohol abuse. This supported the separation of dependence from abuse. Abuse diagnoses were associated with some, but not all, criterion variables when compared with subjects with no diagnosis. This report replicates many aspects of a similar investigation in a community sample of household residents. Implications for the next steps in research are discussed.