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The general population of one major city supports the use of needle exchange programs even though many think such a program might attract injection drug users (IDU's) to their neighborhoods. In Baltimore, Maryland, a group of 138 people demographically similar to the city's overall population responded to a survey on needle exchange. While 72% thought such a program might attract IDU's to the neighborhood, 65% favored such a program because it would decrease the number of discarded needles; would not increase drug use, and that it would decrease HIV transmission.

Self-reported information about health and mental health status and history on (a) three diverse samples of individuals who reported multiple chemical sensitivities syndrome (n = 60) and (b) one sample of the general population (n = 60) was collected by telephone interview. Subjects from the general population were selected randomly from the telephone directory and were matched for age, gender, and socioeconomic status with index subjects. Data on an additional 10 subjects with multiple chemical sensitivities syndrome were also available for comparison on many of the variables of interest. The four diverse groups of patients with multiple chemical sensitivities syndrome had very similar general and specific indices of illness and sensitivity to chemicals. Members of the general population reported mild sensitivity to chemicals, and even those with more sensitivity differed from the multiple chemical sensitivities syndrome groups with respect to number and types of symptoms reported, duration and frequency of response, and associated features. Multiple chemical sensitivities syndrome was associated consistently with only one psychiatric variable, elevated negative affect scores, which were correlated significantly with the presence of illness. Patients with multiple chemical sensitivities syndrome from the diverse samples had very similar characteristic features, despite whether they had or had not received treatment by clinical ecologists., ASHFORD AND MILLER[1] postulated that three populations are at special risk for developing a persisting hypersusceptibility to very low levels of environmental chemicals: (1) people who experience nonspecific building-related illnesses, [...]

Objective: To examine students' knowledge, barriers to access, and use of services at two school-based health centers. Design: In-person survey. Settings: Two urban public schools in Baltimore, Md. Participants: One hundred forty-nine middle school and 131 high school African-American students. The response rate was 84%. Main Outcome Measures: Knowledge about center operations and services, reported barriers to access to the center, and reported use of the center. Results: Knowledge about center operations and services was generally high. However, knowledge was low with respect to the need for an appointment for nonemergency visits (40% correct) and the availability of dental service referrals (51% correct). One fifth of students incorrectly reported their enrollment status. Boys were more likely to report that they knew about the availability of sports physical examinations (odds ratio, 3.7), and girls were more likely to report that they knew about reproductive services (odds ratio, 3.0). The most frequently identified barriers to access were difficulty in obtaining a teacher's permission to leave class (55%), requiring parental permission for enrollment (3 1%), and concern about confidentiality (26%). Barriers to access were reported more frequently by students in the middle school than by students in the high school. Seven eighths of enrolled students reported that they had used the center in the past year, but only a third would use it if they woke up on a Monday with a bad cough and needed to see a physician or nurse. Conclusion: Despite increasing the availability of primary care services by locating health centers in schools, some barriers to access remain. School-based health centers could more actively promote awareness of their operation and services among students and their parents. (Arch Pediatr Adolesc Med. 1996;150:175-180), Lack of knowledge and other barriers may prevent optimal use of school-based health clinics. A group of 149 inner-city middle-school and 131 high-school students attending a middle-school and a high school with on-site health clinics responded to a questionnaire. Knowledge of operations and services was generally good, but only 40% of the group knew an appointment was needed for nonemergency visits. One-third of the group did not know that mental health services were available and half did not know dental referrals could be made. Sixty-two percent of boys versus 83% of girls knew reproductive health care was available. Over half the students reported that getting permission to leave class was a barrier to obtaining health care services, and nearly one-third reported the need to get parental consent to enroll. About one-quarter had concerns about confidentiality or found clinic hours a barrier. Parental consent problems usually arose from a lack of involvement or failure to return forms, not parental refusal.

When abnormal psychologic/psychiatric symptom data are obtained on personality tests or psychiatric interviews administered to patients who report symptoms of Multiple Chemical Sensitivities Syndrome, investigators typically attribute these to either psychiatric traits or to psychogenic origins of illness. The primary purpose of these studies was the evaluation of the plausibility of nonpsychiatric explanations of psychologic/psychiatric symptom data. In Study 1, patients with Multiple Chemical Sensitivities Syndrome used the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) to describe which items had changed after they developed the condition. In Study 2, three diverse groups of professionals predicted which items on the MMPI-2 might change after a mentally healthy person developed the Syndrome or a condition resembling it. In Study 3, a second sample of Multiple Chemical Sensitivities Syndrome patients completed the MMPI-2 and other questionnaires by mail, which allowed the authors to ascertain whether these patients showed more or different psychopathology than was described by patients and hypothesized by professionals. Data from Study I patient informants indicated that developing the syndrome might result in a psychopathological MMPI-2 profile, characterized by abnormal Hypochondriasis and Hysteria scale scores. Professionals in Study 2 showed a consensus about hypothesized MMPI-2 changes following the development of the syndrome. These changes likely elevated the Hypochondriasis, Hysteria, Psychasthenia, Depression, and Schizophrenia scale scores. In Study 3, the patients taking the MMPI-2 showed elevations on the Hypochondriasis, Hysteria, Depression (women only), and Schizophrenia scales. Abnormal scores were associated closely with greater severity of illness and greater adjustment to illness. The strategy of administering psychometric tests to ill populations for the purposes of evaluating psychiatric illness or traits, and/or psychogenic origins of illness was shown to be potentially misleading., MULTIPLE CHEMICAL SENSITIVITIES (MCS) Syndrome lacks a standard case definition, but, in a recent survey[1] it was characterized by a majority of physician respondents. They defined MCS Syndrome as a [...]

Context: Adolescent suicide rates have increased dramatically in recent decades. Suicide is the third leading cause of mortality among persons aged 10 to 19 years. Several official guidelines recommend screening for suicidal behavior in the primary care setting. Objectives: To determine the prevalence of adolescent suicidal behavior known to primary care providers and to determine the knowledge, attitudes, and practice of primary care physicians in Maryland regarding screening for risk factors for adolescent suicide. Design: Cross-sectional study using mailed survey. Setting: Maryland from May to July 1995. Participants: All pediatrician (n = 816) and family physician (n = 592) members of the state chapter of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively, who were actively providing ambulatory care. Main Outcome Measures: Adolescent suicidal behavior known to primary care providers and predictors of routine screening for risk factors for adolescent suicide. Results: The response rate was 66%. Three hundred twenty-eight physicians (47%) reported that 1 or more adolescent patients attempted suicide in the previous year, but only 158 (23%) either frequently or always screened adolescent patients for suicide risk factors. Significant factors correlating with routine screening for suicide risk factors included frequently or always counseling about the safer storage of firearms in the home (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.8-10.2); agreeing or strongly agreeing that they were sufficiently trained and knew how to screen for risk factors (OR, 3.2; 95% CI, 1.7-6.3); agreeing or strongly agreeing that they had enough time during the well visit to screen for mental health problems (OR, 2.9; 95% CI, 1.6-5.3); frequently or always counseling about child passenger safety (OR, 2.7; 95% CI, 1.6-4.7); spending more than 5 minutes in anticipatory guidance during the well visit (OR, 2.7; 95% CI, 1.5-4.6); practicing in an urban setting (OR, 2.3; 95% CI, 1.2-4.7); agreeing or strongly agreeing that physicians can be effective in preventing adolescent suicide and that what they do during an office visit may help prevent adolescent suicide (OR, 2.0; 95% CI, 1.2-3.4); and female sex (OR, 1.9; 95% CI, 1.1-3.2). Conclusions: Despite the substantial proportion of primary care providers who encountered suicidal adolescent patients, most providers still do not routinely screen their patients for suicidality or associated risk factors. More training is needed and desired by the survey respondents. Patient confidentiality issues must be addressed. Development and widespread use of a short, easily administered, reliable, and valid screening tool are recommended to help busy clinicians obtain more complete information during all visits. Arch Pediatr Adolesc Med. 2000; 154:162-168, Primary care physicians may have an opportunity to prevent teenage suicides by screening for risk factors such as depression, physical or sexual abuse, alcohol use, or prior attempts. Of 693 physicians who completed surveys, 328 (47%) had at least one adolescent patient who attempted suicide in the previous year, with the number of attempts ranging from one to 15 per practice. During the 12 months prior to the survey, 20% of students in grades 9 through 12 had seriously considered attempting suicide, 16% had made a specific plan, 8% had actually attempted, and 2.6% had made an attempt requiring medical attention.

Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

In the treatment of severe intraventricular hemorrhage (IVH), thrombolytic use and clot size are known to influence clot lysis rates. We evaluated the effect of other variables on IVH clot lysis rates among patients treated with recombinant tissue-type plasminogen activator or placebo.

Patients with intracerebral hemorrhage and intraventricular hemorrhage have a reported mortality of 50 to 80. We evaluated a clot lytic treatment strategy for these patients in terms of mortality, ventricular infection, and bleeding safety events, and for its effect on the rate of intraventricular clot lysis.

Background

Introduction:To test the feasibility and safety of a minimally invasive technique, we report our experience in treating spontaneous intracerebral hemorrhage (ICH) patients by using frameless stereotactic clot aspiration-thrombolysis and its effects on their 30-day survival. We compared the observed cohort mortality with its predicted 30-day ICH mortality, by using previously validated methods.

Objective:The impact of early transcranial Doppler ultrasonography (TCD) upon stroke subtype diagnosis is unknown and may affect therapeutic strategies. In this study, the diagnostic usefulness of TCD in stroke subtype diagnosis according to the criteria of the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) study was investigated in patients with acute cerebral ischemia. Methods:TCD examination within 24 h of symptom onset was performed in 50 consecutive patients with acute cerebral ischemia. Of these 54% were female. Sixty percent of patients were black, 36% white, and 4% Asian. Initial TOAST stroke subtype diagnosis (ITSSD) was based upon clinical presentation and initial brain imaging studies. Modified TOAST stroke subtype diagnosis was determined subsequently after additional review of the TCD examination. Final TOAST stroke subtype diagnosis was determined at hospital discharge, incorporating all diagnostic studies. Using final TOAST stroke subtype diagnosis as the ‘gold standard’ ITSSD and modified TOAST stroke subtype diagnosis were compared in order to determine additional benefit from the information obtained by TCD. Data were collected retrospectively by a single investigator. Results:ITSSD classified 23 of 50 (46%) patients correctly. After TCD, 30 of 50 (60%) patients were classified correctly, for an absolute benefit of 14% and a relative benefit of 30% (p = 0.018). Most benefit from TCD was observed in the TOAST stroke subtype category large-artery atherosclerosis, in particular in patients with intracranial vascular disease. In this category, ITSSD had a sensitivity of 27% which increased to 64% after TCD (p = 0.002). Conclusion:TCD within 24 h of symptom onset improves the accuracy of early stroke subtype diagnosis in patients with acute cerebral ischemia due to large-artery atherosclerosis. This may have clinical implications for early therapeutic interventions.

Abstract. Objective: To determine which neurologic signs or symptoms are predictive of new focal lesions on head CT in HIV‐infected patients. Methods: Prospective study with convenience sample enrollment of HIV‐infected patients who presented to a large inner‐city university‐based ED over an 11‐month period. Patients were assessed using a standardized neurologic evaluation to ascertain whether they had developed new or changed neurologic signs or symptoms. Patients with any new or changed neurologic findings had a head CT scan in the ED. The association between individual complaints or findings and new focal lesions on head CT was assessed by univariate analysis, and sensitivity, specificity, and positive predictive values were calculated. Stepwise logistic regression analysis was then carried out to estimate the relative risk for those variables independently associated with new focal lesions on CT scans. A decision guideline was developed incorporating those variables. Results: One hundred ten patients were identified as having new or changed neurologic signs or symptoms and had a head CT done in the ED. Twenty‐seven patients (24%) had focal lesions on head CT, of which 19 (18%) were identified as new focal lesions; eight of these (7%) demonstrated a mass effect. Clinical findings most strongly associated with new focal findings on head CT were: 1) new seizure, relative risk (RR) = 73.5, 95% CI = 6.2 to 873.0; 2) depressed or altered orientation, RR = 39.1, 95% CI = 4.6 to 330.0; and 3) headache, different in quality, RR = 27.0, 95% CI = 3.2 to 230.1. Use of these three findings as a screen for ordering head CT in the ED would have identified 95% (18/19) of the patients with new focal intracranial lesions, and resulted in a 53% reduction in the number of head CTs ordered in the ED. Inclusion of one additional parameter (prolonged headache, ≥3 days), would have resulted in identification of 100% of all new focal lesions, with a 37% reduction in the number of head CTs ordered. Among those patients with new focal findings, 74% required emergent management (i.e., seizure control, IV antibiotics, IV steroids or surgery). The most common intracranial lesion among patients with CD4 counts less than 200 cells/μL was toxoplasmosis, while cerebrovascular accidents (ischemic or hemorrhagic) were most common in those with CD4 counts greater than 200 cells/μL. Conclusion: Specific clinical signs and symptoms were associated with the presence of new intracranial lesions in a group of HIV‐infected patients who presented to the ED with neurologic complaints. These clinical findings can be incorporated into guidelines for determining the need for emergent head CT. Validation and widespread application of these guidelines could result in limiting the use of emergent neuroimaging to a more well‐defined HIV‐infected patient population.

• We analyzed the onset of agoraphobia in a large prospective study of the general population. The annual incidence of Diagnostic Interview Schedule/DSM-III agoraphobia is estimated at 22 per 1000 population per year. Latent class analysis of new cases in the at-risk population reveals the existence of two subtypes of agoraphobia. The relationship of the incidence of the two subtypes to sociodemographic and psychopathologic risk factors suggests different origins. The data also show that in two thirds of the 260 new cases of Diagnostic Interview Schedule/DSM-III agoraphobia, onset occurs without a history of panic attack. We analyzed the relationship of these epidemiologic results to earlier clinical findings in terms of possible measurement and sampling differences.

Objective:To examine the predictive power of self‐rated health, activities of daily living (ADL), and ambulatory activity for different causes of death in a representative sample of older persons.

Abstract. Objective:To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes.

Abstract. Objective: To examine the population and geographic patterns, patient characteristics, and clinical presentations and outcomes of alcohol‐related ED visits at a national level. Methods: Cross‐sectional data on a probability sample of 21,886 ED visits from the 1995 National Hospital Ambulatory Medical Care Survey were analyzed with consideration of the individual patient visit weight. The annual number and rates of alcohol‐related ED visits were computed based on weighted analysis in relation to demographic characteristics and geographic region. Specific variables of alcohol‐related ED visits examined included demographic and medical characteristics, patient‐reported reasons for visit, and physicians' principal diagnoses. Results: Of the 96.5 million ED visits in 1995, an estimated 2.6 million (2.7%) were related to alcohol abuse. The overall annual rate of alcohol‐related ED visits was 10.0 visits per 1,000 population [95% confidence interval (CI) 8.7–11.3]. Higher rates were found for men (14.7 per 1,000, 95% CI 12.5–16.9), adults aged 25 to 44 years (17.8 per 1,000, 95% CI 15.0–20.6), blacks (18.1 per 1,000, 95% CI 14.0–22.1), and residents living in the northeast region (15.2 per 1,000, 95% CI 12.1–18.2). Patients whose visits were alcohol‐related were more likely than other patients to be uninsured, smokers, or depressive. Alcohol‐related ED visits were 1.6 times as likely as other visits to be injury‐related, and 1.8 times as likely to be rated as “urgent” or “emergent.” The leading principal reasons for alcohol‐related ED visits were complaints of pain, injury, and drinking problems. Alcohol abuse/dependence was the principal diagnosis for 20% of the alcohol‐related visits. Conclusion: Alcohol abuse poses a major burden on the emergency medical care system. The age, gender, and geographic characteristics of alcohol‐related ED visits are consistent with drinking patterns in the general population.

A high correlation between continuous measures of self-reported and measured weight and height has led investigators to infer that self-report of these variables is appropriate in epidemiologic studies. We evaluated the sensitivity and specificity of categorical definitions of body mass defined using self-reported height and weight on 7,455 adult participants of the Lipid Research Clinics Family Study (1975–1978) on whom both self-reported and measured height and weight were available. The categorical definition of obesity used here was a body mass index of at least 30 kg/m2. Overall, the sensitivity of the obese category when defined with self-reported weight and height was 74 (95 CI = 72–76), and the specificity was 99. The sensitivities of the categories defined using self-reported measures varied considerably by sex, age, and educational level. Overall, the sensitivities were higher for women compared with men, as men were less accurate in reporting height. The sensitivity of the categorical definitions of obesity decreased with increasing age and education in both men and women. The sensitivity for elderly obese men was below 50. These results suggest that substantial misclassification can occur when self-reported information is used to define body mass categories.

Neonatal tetanus is the cause of 23 to 73% of neonatal deaths in developing countries and continues to be an important killer in many parts of India.

This study examines the relationship between menopausal estrogen and estrogen-progestin replacement therapy and risk of breast cancer, focusing on whether associations differ according to whether the tumors arein situ or invasive. Data are from a prospective study conducted 1980–89 on 49,017 selected participants in the Breast Cancer Detection Demonstration Project, a five-year screening program conducted between 1973 and 1980 in the United States. Overall, the rate ratio for estrogen-only use compared with no-hormone use was 1.0, and that for the estrogen-progestin combination was 1.2 (95 percent confidence interval [CI]=1.0–1.6). However, the associations differed according to whether the tumors werein situ or invasive. The rate ratios ofin situ breast cancer associated with use of estrogens alone and the combination regimen were 1.4 (CI=1.0–2.0) and 2.3 (CI=1.3–3.9), respectively. Duration of estrogen-only use also was associated with risk ofin situ tumors, with users for 10 or more years at twice the risk of nonusers (P-value for trend test =0.02). Duration of use was not associated with risk of in vaisve cancer. Our results are consistent with the hypothesis that hormone replacement therapy is related to earlier-stage breast cancer; however, the possibility that the results reflect increased breast cancer surveillance among those taking hormones cannot be ruled out.

In Reply.—Since blood pressure is a variable that is influenced by a host of factors and its measurement is associated with errors, the issue in a trial such as the Hypertension Prevention Trial (HPT) is not whether there is variability and error, but rather the influence they have on the results observed. Clearly, the greater the variability of a measure, the more difficult it is to find differences among the treatment groups because of a lack of precision of the measurement. Recognition of this is the reason the investigators in the HPT devoted considerable time and resources to standardization of the measurement process by training blood pressure observers, by use of random zero sphygmomanometers, and by continuous monitoring of the measurement process.1 Indeed, one might argue that the observation of blood pressure differences among the treatment groups is even more noteworthy because it emerges in spite of the