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This study investigated pretreatment variables associated with depression severity in adolescents following maintenance treatment for major depressive disorder (MDD). Data was derived from the Treatment for Adolescents with Depression Study (TADS). Participants received one of three treatments: cognitive behavioral therapy (CBT), fluoxetine (FLX), or combined CBT and fluoxetine (COMB). Participants received 12 weeks of acute treatment, 6 weeks of consolidation treatment, and 18 weeks of maintenance treatment (N = 327, M age = 14.62 yrs). Outcome was measured by the Children's Depression Rating Scale-Revised. Results showed adolescents with shorter depressive episodes, better global functioning, less suicidal ideation, better health/social functioning, and greater expectancy of positive treatment response were more likely to have lower depression severity following 36 weeks of treatment, regardless of modality. Adolescents with lower initial depression demonstrated lower depression severity if treated with CBT. FLX was more effective in reducing depression severity in adolescents with severe baseline depression than for those with mild or moderate depression. Adolescents with higher family incomes were more likely to have lower depression severity if they received CBT only. In conclusion, adolescents with shorter depressive episodes, better health, social, and global functioning, less suicidal ideation, and greater expectancy for treatment at baseline respond equally well to CBT, fluoxetine, and combined treatment. Adolescents who are more severely depressed at baseline may have a better treatment response if they are treated with FLX; whereas adolescents of higher income are more likely to have a better response if they receive CBT only.

The Workers' Compensation Board of British Columbia requested a retrospective analysis of all fishermen's deaths from immersion in water in British Columbia.To identify the underlying cause of drowning and make recommendations to improve safety in the fishing industry.Eighty-nine inshore and offshore fishing accidents were analysed. Where possible, deaths were classified into the four stages of cold-water immersion: cold shock, swimming failure, hypothermia and post-rescue collapse. Other factors that led up to the drowning were also identified.One hundred and thirty fishermen died from immersion between 1976 and 2002. One hundred and twenty-eight drownings were certified by the coroner as drowning or drowning/hypothermia and two were certified as cardiac event after immersion. The underlying causes of drownings were reclassified as: cold shock (5.4%), swimming failure (5.4%), hypothermia (5.4%), post-rescue collapse (0.8%), cardiac event (0.8%) and drowning/other (10%). In the remaining 72.2% of deaths, there was insufficient information to determine an underlying cause. All deaths occurred in water below 17.5 degrees C but 95% were in water less than 15 degrees C.Immersion in water below 15 degrees C is dangerous and this should be emphasized on marine survival courses. Accident investigators, coroners and pathologists need a common checklist to record vital data. A recommended format is included as Supplementary data available at Occupational Medicine Online. Fishermen should be educated about the dangers of sudden, unexpected immersion in cold water. Consideration should be given to making marine survival courses mandatory for fishermen.

Objective: The prevalence of cleft lip and/or palate (CL/P) in Northern Ireland (NI) was last reported for 1980 through 1990. This study was undertaken to update the prevalence of CL/P in NI for the 20-year period 1981 to 2000, to determine the pattern of prevalence, and to report the proportion of different cleft types and sex distribution. Design: Retrospective, population-based analysis. Patients/participants: All live born children with CL/P in NI from 1981 to 2000 were included. A total of 750 cases were identified. Resident births outside NI, stillbirths, abortuses, and children born with atypical orofacial clefts were excluded. Those with syndromes and submucous clefts were included in the study. Results: The overall prevalence of children born with CL/P within NI for the period 1981 to 2000 was 1.47 per 1000 live births, or 1:682. This was consistent with the findings reported by other U.K. studies. There were no significant changes in the prevalence rates over any 5-year period. No significant seasonality trends were noted. Clefts of the palate only were always in the majority. More boys than girls were affected by cleft lip with or without cleft palate. There was a significant left-sided predilection for unilateral clefting of the lip. Conclusions: There have been no significant changes in the birth prevalence of children born with CL/P or the distribution or laterality of cleft type in the NI population during the past 20 years.

This was to investigate what coping strategies are used by children, the efficacy of these strategies and the influences of age, gender, dental anxiety, pain experience and childhood caries prevalence (place of residence) upon the efficacy of the coping strategies used by Dutch (NL) children in The Netherlands and Northern Ireland (NI).Convenience samples of Dutch and NI children were taken and asked to fill out a coping questionnaire (Dental Cope Questionnaire) and an anxiety schedule (CFSS-DS). Data were entered onto a SPSS database and subjected to frequency distributions, Chi-square analysis, t-tests and analysis of variance.The children used a wide variety of coping strategies in dealing with pain in dentistry. The most frequently used and those reported to have the greatest efficacy by the children in this investigation were cognitively based strategies. Different strategies were used in relation to place of residence, age and level of dental anxiety. The variance in the number of strategies used was significantly explained by the experienced pain during dental treatment. The efficacy of the coping strategies used was significantly explained by level of dental anxiety.Dental coping strategies used by children seem to vary with age, dental anxiety and pain experience. This information can help dental practitioners to adjust his or her treatment to the child's emotional needs.

The aims of this study were to understand the attitudes of local law enforcement staff regarding policies to reduce youth access to tobacco, to determine what proportion of these agencies have conducted unannounced compliance checks in the past year, and to examine factors associated with conducting compliance checks.A written questionnaire was completed by 182 law enforcement officials representing 200 cities and counties in California (some officials represented multiple jurisdictions). Logistic regression analyses were conducted to identify factors associated with conducting compliance checks.Only 36% of local enforcement agencies reported conducting one or more compliance checks in the previous year. Agencies were more likely to conduct compliance checks if they perceived fewer barriers to enforcement, reported more frequent collaboration with other community agencies to enforce youth access laws, and believed that youth access to tobacco is a problem in their community.Because active enforcement of youth access laws using unannounced compliance checks has been shown to reduce the rate of illegal tobacco sales to minors and may reduce youth smoking, efforts to increase the level of enforcement should be promoted. These study results may be used to inform efforts to encourage local agencies to enforce existing youth access laws.

The dosage model provides a normative estimate of the overall pattern of patient improvement in psychotherapy. The phase model further specifies patterns of change in the domains of subjective well-being, symptom remediation, and functioning. The expected treatment response (ETR) approach uses patient characteristics to predict an expected path of progress for each patient. With repeated measures of mental health status, the treatment progress of an individual patient can be assessed against the patient's ETR to support decisions that would enhance the quality of a clinical service while it is being delivered.

Cost savings, cost avoidance, and cost reduction are important factors to measure when valuing clinical pharmacy services. Currently, there are no universally accepted definitions for these terms. The authors of this study evaluated 44 articles which claimed to measure cost savings, cost avoidance, or cost reduction associated with clinical pharmacy services, and offered recommendations for when it would be appropriate to use these terms. Based on the results of our analysis, it is evident that controversy exists in the literature when determining if services result in cost avoidance or cost reduction. Therefore, there is a need for universally accepted definitions of these terms so that future research may evaluate such factors uniformly.

The growing emphasis on using empirical data to guide mental health policy decision making has contributed, in part, to a developing dichotomy along the continuum of research on mental health interventions. At one end of the continuum is research on the efficacy of mental health interventions, traditionally referred to as clinical trials research. The goal of clinical trials research is to determine whether or not a specific intervention can be shown to be efficacious for a specific problem. At the other end of the continuum is research on the implementation and evaluation of mental health interventions, traditionally referred to as mental health services research. The goals of mental health services research are to understand the access to, organization and financing of, and outcomes of mental health interventions. The conceptual, methodological, and measurement features of both types of research are presented and suggestions are offered to bridge the gap between the two paradigms. The purpose of this article is to highlight each discipline's unique contributions to mental health research and, in so doing, facilitate a discussion that fosters scientific integration and collaboration between clinical trials and mental health services investigators.

Patient injuries are thought to have a substantial financial impact on the health care system, but recent studies have been limited to estimating the costs of adverse drug events in teaching hospitals. This analysis estimated the costs of all types of patient injuries from a representative sample of hospitals in Utah and Colorado. We detected 459 adverse events (of which 265 were preventable) by reviewing the medical records of 14,732 randomly selected 1992 discharges from 28 hospitals. The total costs (all results are discounted 1996 dollars) were $661,889,000 for adverse events, and $308,382,000 for preventable adverse events. Health care costs totaled $348,081,000 for all adverse events and $159,245,000 for the preventable adverse events. Fifty-seven percent of the adverse event health care costs, and 46% of the preventable adverse event costs were attributed to outpatient medical care. Surgical complications, adverse drug events, and delayed or incorrect diagnoses and therapies were the most expensive types of adverse events. The costs of adverse events were similar to the national costs of caring for people with HIV/AIDS, and totaled 4.8% of per capita health care expenditures in these states.

Patient profiling predicts improvement across psychotherapy sessions on the basis of intake clinical characteristics. Patients completed questionnaires before their 1st session and at other points during treatment. After using hierarchical linear modeling to calculate expected courses of improvement, 1/2 of the sample was divided into 1 of 2 groups: those whose treatment responses across sessions matched or exceeded their expected courses (75% of the sample) and those whose responses failed to match expectations. A discriminant function analysis indicated that the groups could be differentiated on the basis of intake characteristics; that is, patients with higher discriminant scores were more likely than those with low discriminant scores to have responded to psychotherapy as predicted. Successful cross-validation of the predictor weights was performed with the other 1/2 of the sample.

HeLa X human skin fibroblast hybrid cells have been developed into a model for radiation-induced neoplastic transformation of human cells. Previous studies indicate that the appearance of neoplastically transformed foci in this system is delayed for several population doublings after irradiation and appears to involve the loss of putative tumor suppressor loci on fibroblast chromosomes 11 and 14. We now show that after treatment with 7 Gy of X-rays, transformed foci initiation correlates with delayed apoptosis initiated in the progeny of the irradiated cells after 10-12 cell divisions and with reduced plating efficiency (delayed death). The cells develop classic apoptotic morphology, positive terminal deoxynucleotidyl transferase-mediated nick end labeling and phosphatidylserine (annexin V) staining, and cleavage of poly(ADP-ribose) polymerase. In addition, a delayed induction of the p53 protein and the proapoptotic Bax protein is evident over a week after radiation exposure. We propose that a delayed build-up of mitosis-dependent genomic DNA damage or a loss of genetic material over time (10-12 cell divisions postirradiation) has two relevant outcomes: (a) cell death due to the delayed induction of a p53-dependent apoptosis; and (b) neoplastic transformation of a minor subset of survivors that has lost fibroblast chromosomes 11 and 14 (tumor suppressor loci for this system) and has either evaded apoptosis or not acquired enough genetic damage to induce apoptosis. It is postulated that both phenomena result from X-ray-induced, translesion-mediated genomic instability.

Case studies involving the measurement of every plausibly causal variable and every important outcome variable and covering the widest possible range of cases in terms of these variables are the highest priority for psychotherapy research. Such case studies looked at together will give us the best initial understanding of what variables are probably causal and what treatments yield the best results for particular kinds of patients, therapists, and settings. The accumulation of such case studies will show us where we would benefit by doing comparative controlled experiments of distinct therapies or by employing optimum-seeking designs for a particular therapy. Collaboration by the practitioner community will be needed to do this. The truly difficult and necessary work of applied psychotherapy research still lies ahead of us, hardly touched.

The acquisition of psychotherapy skillfulness is an important aspect of training programs in psychiatry and clinical psychology. Psychotherapy supervision is employed to teach and monitor the development of these clinical skills. The Supervisor Report (SR) is a questionnaire designed to systematically assess therapeutic behaviors and global psychotherapeutic skillfulness of therapists conducting psychodynamic psychotherapy. SRs were employed to examine changes in trainees' skillfulness over the course of training. T-tests were applied to evaluate differences between the average scores of trainees in the first half of their training compared to the last half of their training. Comparisons of the scores for Psychotherapeutic Techniques and assessments of Global Skillfulness were in the predicted direction: Trainees in the advanced portion of their training were rated as more skillful than at the beginning. This study provides some evidence that psychotherapy skillfulness is acquired over time in training.

In the analysis of the impact of clinical interventions, the received wisdom has been that posttreatment scores, with pretreatment scores equated by random assignment or statistically partialed out, should be used to evaluate treatment outcomes. However, posttreatment scores are not generally more reliable than, nor equivalent to, change scores, even with pretreatment scores partialed out of both. Moreover, there are data-analytic methods that indicate how individual patients change, in terms of response curves over time, rather than indicate only how much groups change on the average. These methods take researchers back to the individual data that they ought to use for choosing the specific models of change to be used. To maximize relevance for clinical practice, the results of treatment research should always be reported at this most disaggregated or individual change level, as well as, when appropriate, at more aggregated statistical levels.

Clinical utility research is concerned with how one develops knowledge that can be directly used for improving clinical practice. Some have referred to this domain as "effectiveness" research, but clinical utility implies much more than clinical effectiveness. It also addresses issues of access, transferability, sample specificity, and the uniqueness of each human condition. This special series of papers describe several research programs that have been conducted in applied settings and that illustrate research on clinical utility. These descriptions are modestly representative of the wide applicability of research methods that address the uniqueness of each setting and population and the nature of findings that can be used to guide clinical practice. The papers bridge cultures, countries, settings, and problems. They illustrate some of the advantages of, and some of the knowledge to be gained from conducting controlled research in settings that are devoted to clinical service.

The intraoral antimicrobial activity of four commercial oral products-conventional NaF dentifrice (Crest), baking soda/peroxide/NaF dentifrice (Mentadent), essential oil mouthrinse (Listerine) and SnF2 dentifrice (Crest Plus Gum Care)-have been compared in three test regimens. Formulations were compared for their ability to suppress the regrowth and apical extension of dental plaque following toothbrushing during thirty hours of non-brushing where products were used as oral rinses (30-hour plaque regrowth model). Formulations were also compared for their ability to suppress the colony-forming units (cfu) of facultative anaerobic bacteria sampled from buccal gingival surfaces following use (Gingival Surface Microbial Index-GSMI model). Lastly, formulations were compared for effects in suppressing the glycolytic metabolic activity and regrowth activity of in vivo-treated dental plaques sampled at various periods following topical use and incubated under controlled ex vivo conditions (Plaque Glycolysis and Regrowth-PGRM model). In thirty-hour plaque regrowth testing, the rank ordered antimicrobial efficacy of formulations followed SnF2essential oilsNaF = water = baking soda/peroxide. In GSMI testing, all formulations were shown to suppress the cfu of facultative anaerobic bacteria relative to baseline, although SnF2 treatment was observed to reduce bacterial levels to a significantly greater degree than NaF dentifrice or baking soda/peroxide dentifrice up to two hours following brushing. In PGRM testing, the SnF2 dentifrice provided significant inhibition of bacterial metabolism and regrowth following topical application when compared with the NaF dentifrice as control. The baking soda/peroxide dentifrice provided no reduction in either bacterial metabolism or regrowth in PGRM. Previous studies had demonstrated modest effects for essential oil rinse in reducing PGRM plaque regrowth, with no effects for this treatment on plaque metabolism. Overall, these results demonstrate that SnF2 dentifrice provides substantial intraoral antimicrobial effects. The essential oil mouthrinse also exhibits significant intraoral antimicrobial effects, albeit apparently less than SnF2 dentifrice. The baking soda/peroxide dentifrice did not produce any antimicrobial effects following in vivo use compared with conventional dentifrice. These results provide mechanistic rationale for the chemotherapeutic efficacy of SnF2 and essential oil formulations in reducing gingivitis, while providing no support for the expectation of clinical efficacy for formulations containing baking soda and peroxide.

Platinum-DNA adducts can be measured in peripheral blood leukocytes during platinum-based chemotherapy, and high adduct levels have been correlated with favorable clinical response in patients with germ cell cancer. Twenty-five patients with advanced germ cell cancer were treated with platinum-based chemotherapy regimens using the same dose and schedule of cisplatin. Platinum-DNA adducts were measured by atomic absorption spectrometry on the first and fifth days of the first cycle of cisplatin-based therapy. The patients were followed prospectively for 6-35 months (median, 26 months). Twenty-two patients had adduct levels measured 24 h after the first dose of cisplatin. There was no difference in the mean adduct levels of those who were alive and without progression of disease compared to those who were dead or progressing (P = 0.65). Twenty-three patients had day 5 adduct levels measured. The mean day 5 adduct level in the 15 patients who were alive and without progression was 62.133 fmol/microgram compared to 153.50 fmol/microgram in the patients who were dead or progressing (two-sided P = 0.02). Contrary to previous reports, these data indicate that high platinum-DNA adduct levels do not correlate with favorable outcome in patients with advanced germ cell cancer.

To assess the relationship between state driver's license renewal policies and fatal crashes involving drivers aged 70 years or older (seniors).Poisson regression methods were used to isolate the relationship between different state policies mandating vision tests, knowledge tests, or road tests for driver's license renewal and fatal crashes involving senior drivers. The analysis controlled for differences among states, other than their renewal policies, likely to influence senior motor vehicle crashes.United States, 1985 through 1989.All fatal crashes identified in the National Highway Traffic Safety Administration Fatal Accident Reporting System involving at least one driver aged 70 years or older.The number of fatal crashes per state in which at least one of the drivers was aged 70 years or older. When a single fatal crash involved more than one senior driver, each was included.State-mandated tests of visual acuity, adjusted for license renewal period, were associated with lower fatal crash risk for senior drivers (relative risk, 0.93; 95% confidence interval, 0.89 to 0.97). Knowledge tests, when added to vision tests and applied only to seniors, provided a nonsignificant reduction in the senior fatal crash risk (relative risk, 0.91; 95% confidence interval, 0.79 to 1.05).Tests of vision and knowledge for senior drivers at license renewal merit further attention as a means of improving senior traffic safety.

Using the psychotherapy dosage model in which effect was probability of recovery, this study compared treatment response rates for psychological symptoms. Symptom checklists were administered to 854 psychotherapy outpatients at intake and during treatment. Sixty-two symptoms were grouped into 3 classes on the basis of probit analysis results. Chronic distress symptoms demonstrated the fastest average response rate, whereas characterological symptoms demonstrated the slowest. Acute distress symptoms showed the highest average percentage of patients recovered across doses. A typical outpatient needed about a year of psychotherapy to have a 75% chance of symptomatic recovery. The model holds promise for establishing guidelines for the financing of psychotherapy.

Mental health services research aims ultimately to improve the quality, impact, and cost-effectiveness of services. Experience during the past decade suggests that the goals and study conditions of mental health services research require special methods. This special section presents 7 articles that give a flavor of the issues addressed and some of the methods that characterize this emerging research area. Although the series cannot explicate the full breadth or all the nuances of these methods, our goal is to entice colleagues to join us in developing methods for addressing services research questions.

The rate of administration of an intravenous anesthetic induction agent is an important variable determining the total dose required to reach a given endpoint, such as loss of consciousness (LOC). The influence of infusion rate on the dose-response relationship has not been described rigorously. In this study we characterized the effect of different thiopental infusion rates on the times and doses required to reach a clinical (induction) endpoint.Fifty-six healthy, non-premedicated men, aged 19-59 yr, were randomly assigned to receive one of seven different thiopental infusion rates (40, 60, 75, 150, 300, 600, and 1,200 mg/min). The infusion was continued until the patient dropped a held object, indicating LOC. The infusion rates were selected using a simulation which predicted the relationship between the rate of administration and cumulative dose administered at the time of LOC. Average population pharmacokinetic parameters from a three-compartment thiopental model were combined with an effect-site rate constant for thiopental equilibration of 0.58 min-1 and a median effect-site concentration of 13.8 mg/l from previously published pharmacokinetic and pharmacodynamic models for thiopental. This derived model was used to predict the total amount of thiopental required, at each infusion rate, to produce LOC.The observed median effective doses for infusion rates of 40-150 mg/min were similar and ranged from 296 to 318 mg. Dose requirements increased significantly with increasing infusion rates greater than 150 mg/min; median effective doses for infusion rates of 300, 600, and 1,200 mg/min were significantly different from each other (436, 555, and 711 mg, respectively). The original simulation underestimated the observed thiopental doses at all but the lowest infusion rate. A new simulation was performed using a recently developed combined pharmacokinetic-pharmacodynamic model. This model incorporated a four-compartment thiopental pharmacokinetic model with quantal dose-response data to derive an effect-site rate constant for thiopental equilibration of 0.29 min-1 and a median effect-site concentration for LOC of 11.3 mg/l. The median thiopental doses predicted by this new simulation under the extreme conditions of a 30-fold range of infusion rates were within 13% of the observed doses.In this study we quantified the relationship between the rate of thiopental administration and the resultant cumulative thiopental dose necessary to produce LOC. This study validated a novel pharmacokinetic-pharmacodynamic model based on a four-compartment pharmacokinetic model and infusion quantal dose-response data. Finally, we demonstrated that thiopental dose-response relationships are dependent on drug administration rate, and found that the ability to predict this dependence accurately is influenced by the pharmacokinetics, pharmacodynamics, and median effect-site concentration used to simulate the dose-response relationships.

The caseload of practicing clinicians tends to be unrepresentative of the population of psychotherapy patients. This results from the fact that, although the majority of patients use relatively few treatment sessions, the majority of a clinician's time is spent with longer term cases--a minority of patients consume the majority of services. Here, a stochastic model is used to describe the development of caseloads under 4 different treatment regimens. It is shown that a psychotherapy practice will reach a steady state (a stable case mix) in relatively short time and at that this will limit the open appointment slots available each week to serve new patients. Implications for training and clinic staffing are discussed.

A comparative study of recombinant 51- and 66-kDa subunits comprising equine infectious anemia virus reverse transcriptase (EIAV RT) is reported. Both polypeptides sedimented as stable homodimers (molecular mass, 102 and 132 kDa, respectively) when analyzed by rate sedimentation through glycerol gradients. Consistent with their dimer composition, each preparation displayed considerable levels of both RNA- and DNA-dependent DNA polymerase activity on different homopolymeric template/primer combinations. However, a detailed analysis of the polymerization products indicated qualitative differences. Whereas p66 EIAV RT proceeded essentially unimpaired along both RNA and DNA templates, p51-catalyzed DNA synthesis was interrupted close to or in the immediate vicinity of the primer. A series of "programmed" 2-step polymerization reactions suggests that p51 EIAV RT enters an abortive mode of polymerization. Duplication of this observation with p51 human immunodeficiency virus-1 RT, together with recent observations from murine RT, suggests that lack of a ribonuclease H domain and loss of contact with the nascent product from the polymerase active center have profound consequences on the mode of polymerization.

A 3-phase model of psychotherapy outcome is proposed that entails progressive improvement of subjectively experienced well-being, reduction in symptomatology, and enhancement of life functioning. The model also predicts that movement into a later phase of treatment depends on whether progress has been made in an earlier phase. Thus, clinical improvement in subjective well-being potentiates symptomatic improvement, and clinical reduction in symptomatic distress potentiates life-functioning improvement. A large sample of psychotherapy patients provided self-reports of subjective well-being, symptomatic distress, and life functioning before beginning individual psychotherapy and after Sessions 2, 4, and 17 when possible. Changes in well-being, symptomatic distress, and life functioning means over this period were consistent with the 3-phase model. Measures of patient status on these 3 variables were converted into dichotomous improvement-nonimprovement scores between intake and each of Sessions 2, 4, and 17. An analysis of 2 x 2 cross-classification tables generated from these dichotomous measures suggested that improvement in well-being precedes and is a probabilistically necessary condition for reduction in symptomatic distress and that symptomatic improvement precedes and is a probabilistically necessary condition for improvement in life functioning.

Exogenous ochronosis resulting from the topical application of hydroquinone-containing bleaching creams has been reported to occur almost exclusively in black subjects, and only after use of high concentrations of hydroquinone (greater than 3 percent) for many years. A Mexican-American patient is described who experienced exogenous ochronosis after using 2 percent hydroquinone cream for less than six months.

Five hundred Black Rhodesian women given injections of 150 mg Depo-Provera every 3 months (group A) and 500 women given an injection of 450 mg Depo-Provera every 6 months (group B) were reviewed after 6 months. Group B had a significantly lower rate of defaulters. There was no significant difference between the groups with regard to weight gain, systolic and diastolic blood pressure increase, overall abnormal bleeding patterns and complaints of side-effects. Among those women who reported abnormal bleeding patterns, significantly more in group B had amenorrhoea. There was no significant increase of prolonged bleeding in group B. Among those women who complained of side-effects, significantly more in group B complained of headaches and a bloated abdomen. No pregnancies occurred in either group. The increased annual cost of the 450 mg injections, which was the main reason for women not accepting this regimen, is outweighed by convenience and reduced travel costs. Depo-Provera 450 mg given by 6-monthly injection is well tolerated and effective, and appears to be even more satisfactory as regards continued acceptance than 150 mg given every 3 months.

The authors have introduced an adjunctive procedure for correction of the osseous axial eversion of the first ray with hallux abducto valgus deformity. They believe that recurrence of bunion deformity is reduced with correction of this osseous abnormality. Consecutive illustrations are presented with recognition of the individual surgeon's ability to modify the procedure to allow for correction of deformities associated with hallux abducto valgus.

To investigate factors influencing a resident's decision to participate in obstetrical care, a survey was undertaken of program directors and third-year residents from the 16 Michigan family practice residency programs. Responses indicated that the majority of third-year residents (55%) intended to practice obstetrics on graduation. Rural practice plans were significantly correlated with a decision to practice obstetrics, but suburban practice plans were negatively correlated. Residents who reported the presence of a good family practice obstetric role model were significantly more likely to practice obstetrics; residents deciding against obstetrical practice expressed concerns about legal liability and malpractice fees. These findings have important implications for family practice training programs if obstetrics is to remain a central part of comprehensive family care.

This study addressed whether the fact that the initial screening interview was with the treating therapist or with another clinician differentially affected engagement in treatment for those patients who actually entered psychotherapy. Patients (N = 418) accepted for individual psychotherapy were separated into two groups: (1) those who entered therapy with the same clinician who did the intake screening (same); and, (2) those who saw one clinician for intake screening and were subsequently assigned to another clinician for therapy (different). Chi-square was used to test the hypothesis that a greater proportion of patients who saw the same clinician from the beginning would complete at least 8 sessions of psychotherapy than would those who saw a different clinician. The results indicated that a greater proportion of patients who were assigned to therapy with the same clinician who conducted the initial screening evaluation returned for their next appointment. However, a greater proportion of patients who saw one clinician for intake screening and were assigned another clinician for therapy continued beyond eight sessions.

One context for understanding an adolescent's (or any other individual's) abnormal functioning is an appreciation of normal or modal functioning in the culture to which that adolescent belongs. After decades of research and clinical observation there is no consensus about what constitutes modal adolescent functioning in the United States. Much less is known about adolescent functioning in other cultures. Results were suggestive of large, cross-cultural differences in self-image among normal adolescents. In most areas American teenagers reported the best functioning while Bengali teenagers reported the worst. There were consistent gender differences in self-image across cultures, with adolescent girls showing poorer self-image than adolescent boys in many areas. Results are discussed from the point of view of difficulties in doing cross-cultural psychiatric research and the need for further research in this field.

The whole-body flux and protein-synthesis rates were determined in two groups of adult males aged 20-30 years who were matched for height and weight. [15N]Glycine was used as a tracer. Flux and synthesis rates were calculated from the urinary ammonia 15N excretion enrichment. Group I consisted of international competition level oarsmen, while Group II engaged in no exercise program. Measurement of the urinary nitrogen excretion rate showed that the oarsmen excreted more than twice as much nitrogen as the control group (P less than 0.05).flux and synthesis were 21.3 +/- 3.2 gN/9 hr and 188.7 +/- 59.9 g protein/day for the oarsmen and 16.4 +/- 2.1 g N/9 hr and 201.7 +/- 33.0 g protein/day for the controls. Data are +/- 1 SD for the eight oarsmen and eight controls. The flux values were different at the P less than 0.05 level. We concluded that (i) an exercise program does not lead to an increase in the basal protein turnover rate in adequately nourished individuals.