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Oxidative stress damages DNA in experimental diabetes, and in vitro studies have suggested that it is linked to lipid peroxidation. The objective of the study was to determine whether lipid peroxidation, as assessed with malondialdehyde excretion in recent-onset type 1 diabetes mellitus, is associated with oxidative damage to DNA, as assessed from 8-hydroxydeoxyguanosine excretion. A 3-year longitudinal study of recent-onset type 1 diabetes mellitus was performed. Age- and sex-matched control subjects were studied once. Patients were studied as inpatients at West Virginia University Hospitals. Thirty-seven patients with recent-onset (2-22 months) type 1 diabetes mellitus (male, 10; female, 27) were enrolled in a longitudinal study of oxidative stress. The mean age of the patients was 20 years. None of the patients had hyperlipidemia or were treated with lipid-lowering drugs. Only 1 patient had hypertension and was being treated with beta-adrenergic blocking therapy. Thirty-six patients completed the study; one withdrew after the second evaluation. Lipid peroxidation was assessed by measuring malondialdehyde excretion. Oxidative damage to DNA was assessed from 8-hydroxydeoxyguanosine excretion. Malondialdehyde excretion was increased in the diabetic patients at the first evaluation (2.43 +/- 0.31 micromol/g creatinine), second evaluation (2.34 +/- 0.24), and third evaluation (1.93 +/- 0.15) compared with control subjects (1.51 +/- 0.11) (P < .005). 8-Hydroxydeoxyguanosine excretion, however, was not increased in the diabetic patients. There was no correlation between malondialdehyde and 8-hydroxydeoxyguanosine excretion. We confirmed the presence of oxidative stress in early diabetes as assessed from malondialdehyde excretion. We were unable, however, to confirm oxidative damage to DNA in this cohort of patients; and there was no evidence of a correlation between lipid peroxidation and DNA damage.

Purpose: Although TMZ replaced BCNU as the standard initial chemotherapy in the treatment of GBM, no studies have been reported comparing BCNU with TMZ. We therefore did a retrospective analysis comparing these agents as initial therapy in GBM., Patients and Methods: Eighty-one patients with GBM in our institution received both radiation and chemotherapy as initial treatment after surgery or biopsy; 49 receiving BCNU and 32 TMZ. These were analyzed for overall survival (OS) and progression-free survival (PFS) versus the type of chemotherapy used. The influence of salvage therapy on the outcome was investigated also., Results: Median OS was superior in the TMZ versus the BCNU group (15.9 vs. 11.5 months) and the curves were judged to be significantly different by the log-rank test; P < 0.02. However, PFS was not significantly different between the two groups. Bevacizumab plus irinotecan (BI) was used as salvage therapy in one-third of the TMZ patients but in none of the BCNU patients. When patients receiving BI were omitted from the TMZ group the OS curve overlapped that of BCNU patients., Conclusion: These data suggest that the superior OS of the TMZ-treated GBM patients was not due to better tumor control by TMZ but was possibly related to the newer salvage therapy that was available to them.

The objective of this study was to determine the utility of computed tomography perfusion (CTP) scans in diagnosing acute ischemic stroke (AIS). CTP abnormalities in two contiguous supratentorial levels were correlated with diffusion weighted image (DWI) abnormalities on magnetic resonance imaging (the standard for stroke diagnosis) performed within 1 week in 422 suspected acute ischemic strokes. Of 157 AIS confirmed by DWI, 78 showed CTP abnormalities (sensitivity 49.7%). All of these examinations were performed with a mean of 35 min from the initial emergency department neurological examination. Excluding small non-vascular territory strokes left 77 AIS with a total volume of infarcted tissue of more than 5 cc by DWI. Of these, 71 showed CTP abnormalities (sensitivity 92.2%). Of the 265 patients without AIS, none showed CTP abnormalities (specificity 100%). CTP is a rapid, readily available and effective method of diagnosing AIS in clinical practice, particularly the major intracranial vessel strokes that result in a more devastating outcome.

Objectives: We investigated the relation between respiratory symptoms and exposure to water-damaged homes and the effect of respirator use in posthurricane New Orleans, Louisiana., Methods: We randomly selected 600 residential sites and then interviewed 1 adult per site. We created an exposure variable, calculated upper respiratory symptom (URS) and lower respiratory symptom (LRS) scores, and defined exacerbation categories by the effect on symptoms of being inside water-damaged homes. We used multiple linear regression to model symptom scores (for all participants) and polytomous logistic regression to model exacerbation of symptoms when inside (for those participating in clean-up)., Results: Of 553 participants (response rate = 92%), 372 (68%) had participated in clean-up; 233 (63%) of these used a respirator. Respiratory symptom scores increased linearly with exposure (P < .05 for trend). Disposable-respirator use was associated with lower odds of exacerbation of moderate or severe symptoms inside water-damaged homes for URS (odds ratio (OR) = .51; 95% confidence interval (CI) = 0.24, 1.09) and LRS (OR = 0.33; 95% CI = 0.13, 0.83)., Conclusions: Respiratory symptoms were positively associated with exposure to water-damaged homes, including exposure limited to being inside without participating in clean-up. Respirator use had a protective effect and should be considered when inside water-damaged homes regardless of activities undertaken.

Unlabelled: Staffing of rural emergency departments (ED) with residency-trained, board certified emergency physicians has been an ongoing challenge in the field of Emergency Medicine., Objectives: To describe the West Virginia (WV) emergency medicine (EM) workforce and make comparisons with the most recent (1999) national EM workforce study and the 1996 WV rural EM workforce study., Methods: A cross sectional mail survey of all non-governmental emergency departments (EDs) in WV was performed from 10/04-12/04. Subgroup analysis of rural EDs using the 1996 WV rural EM study criteria was conducted. Data collected included: number of physicians, residency training, board certification, ED volume, and the number and type of specialty services available., Results: Surveys were mailed to 55 EDs, with a 71% response rate (N=39) describing 310 physicians. Overall, 51% of physicians were either trained and/or board certified in EM, versus 62% in the 1999 national study. In the rural subgroup, 32% were either residency trained and/or board certified in EM, versus 12% in the 1996 WV study., Conclusions: Just over half of all physicians staffing WV's EDs are residency trained or board certified in EM, a number that lags well behind the national average. Rural EDs report even lower numbers, although the proportion has increased since the 1996 WV study. WV EM practitioners, particularly in more rural locations, continue to provide emergency care with less formal training, certification credentials, and specialty back-up.

Purpose: To compare point-resolved spectroscopy (PRESS) and localized two-dimensional (2D) correlated spectroscopy (L-COSY) in the detection of cerebral metabolites in humans on a clinical scanner at 3T and to estimate their respective inter- and intrasubject variances., Materials and Methods: Measurements were made on nine healthy subjects to assess intersubject variance, and daily on a single subject over a period of seven days to assess intrasubject variance. All L-COSY measurements were performed with a voxel size of 27 mL (3 x 3 x 3 cm(3)) and a measurement time of approximately 34 minutes in the occipitoparietal lobe of the brain. Relative metabolite concentrations were estimated with respect to N-methyl creatine., Results: While the sensitivity of PRESS is twice that of L-COSY, the greater spectral resolution offered by L-COSY resulted in greater consistency in estimates of the concentrations of several cerebral metabolites, as indicated by a superior intraclass correlation and a significantly lower standard deviation (SD) in a matched pair intrasubject analysis., Conclusion: Our pilot results demonstrate that L-COSY is an effective approach for resolving cerebral metabolites, and demonstrates a lower coefficient of variance (CV) than the conventional 1D localized spectroscopic approach using LC Model for quantification., ((c) 2007 Wiley-Liss, Inc.)

A retrospective analysis was conducted of 79 consecutive patients who underwent enhanced external counterpulsation (EECP) at West Virginia University Hospitals during the period of November 1998 to September 2005 to determine its efficacy and safety in treating angina. A chart review and/or phone survey was performed to analyze pertinent clinical data (sublingual nitroglycerin use and angina class) pre and post EECP. A total of 60 (76%) patients who were referred for EECP successfully finished the 35 treatments. Seventy-five percent of the patient population improved at least one angina class after a full course of treatment. Therapy was discontinued due to adverse effects in 12 (15%) patients. Statistically significant improvements in angina class and reduction in anti-angina medications were observed in every co-morbid subgroup analyzed, including patients with peripheral vascular disease, diabetes, hyperlipidemia, hypertension, smoking, Post-MI, and LVEF < 40% (P < .05, Wilcoxon Signed-Rank test). Overall, EECP was effective in improving angina as reflected in a substantial reduction in antiangina medications in 59 (75%) patients.

Febrile neutropenia is an expected complication during treatment of aggressive hematological malignancies and hematopoietic cell transplantation. We conducted a prospective cohort trial to determine the effects and safety of prophylactic fluoroquinolone administration, and rotation of empiric antibiotics for neutropenic fever in this patient population. From March 2002 through 2004, patients were treated with prophylactic levofloxacin during prolonged neutropenia, and a cycling schedule of empiric antibiotic therapy for neutropenic fever was initiated. The rates of bacteremia, resistance and complications were compared to a retrospective cohort of previously treated patients. The rate of gram-negative bacteremia decreased after the initiation of prophylactic levofloxacin (4.7 vs 1.8 episodes/1000 patient days, P<0.05). Gram-positive bacteremia rates remained unchanged, but more isolates of Enterococcus faecium were resistant to vancomycin after the intervention began. Resistance to the antibiotic agents used in the rotation did not emerge. There was no change in mortality during the intervention period. A prophylactic and cycling antibiotic schedule was successfully implemented on a hematological malignancy and hematopoietic cell transplant unit. gram-negative bacteremia was significantly decreased, without emergence of resistance. Concerns with Gram-positive resistance will require further observation.

Arterial partial pressure of carbon dioxide (paCO(2)) is commonly evaluated by an invasive test, the arterial blood gas analysis (ABG). The sodium [(13)C]bicarbonate breath test (SBT) can potentially estimate arterial paCO(2). We studied 55 subjects with respiratory disorders and performed the ABG and the SBT to determine if the SBT can predict hypercapnia. The percentage of (13)CO(2) recovered in exhaled breath at 30 minutes (PDR(30)) alone was able to discriminate clinically significant hypercapnia (>53 mmHg) with a sensitivity of 82 % and specificity of 93 % (p<0.001). To evaluate the clinical utility of the SBT as a non-invasive substitute to repeated ABG, we monitored the progress of seven chronic obstructive pulmonary disease (COPD) patients on therapy with both the ABG and the SBT. The PDR(30) values from the SBT were able to correctly predict improvement or worsening of paCO(2) with 100 % accuracy. In conclusion, the SBT is a simple test that can be used in clinical practice to detect clinically significant hypercapnia and monitor COPD patients before and after therapy.

Purpose: To demonstrate the feasibility of estimating the relative intra- and extramyocellular lipid (IMCL and EMCL) pool magnitudes and calculating the degree of lipid unsaturation within soleus muscle using single-voxel localized one- and two-dimensional (1D and 2D) MR spectroscopy (MRS)., Materials and Methods: Localized 1D point resolved spectroscopy (PRESS) and 2D correlation spectroscopy (L-COSY) were performed in identical locations in the soleus muscle of 10 healthy subjects. A GE 3-T MRI/MRS scanner and a quadrature extremity transmit/receive coil was used., Results: The 1D and 2D MR spectra were used to compute IMCL/creatine (Cr) and EMCL/Cr ratios. In addition to cross peaks between the methyl and methylene protons in the high-field region, the 2D spectra showed cross peaks due to J-coupling between allylic, diallylic methylene pro- tons, and olefinic protons. The cross-peak volume ratios also provided a measure of double bonds, suggesting that this ratio can be used to assess unsaturation within IMCL and EMCL lipid pools., Conclusion: We have demonstrated the feasibility of detecting 2D cross peaks between different groups of IMCL and EMCL, including the unsaturated protons within these two lipids pools. This protocol may be easily extended to study the lipids present in other tissues.

Health profession students work in close proximity to patients and could be a source of nosocomial influenza. We studied the proportion of health profession students presenting for immunization at an influenza immunization campaign. This assessment is useful to guide future campaigns as we prepare for pandemic influenza.

Context: Referral bias reflecting the preferential hospital transfer of patients with intracerebral hemorrhage (ICH) has been demonstrated as the major contributing factor for an observed high nonrisk-adjusted in-hospital crude acute stroke mortality rate at a rural academic medical center., Purpose: This study was done to assess the impact of a clinical acute stroke program upon referral bias in August 2000., Methods: A chart review of acute stroke (DRG 14) discharges during 2001 from a rural academic medical center was compared with the same data from 1999., Results: The odds ratio of ICH in hospital-transfer patients compared with nonhospital-transfer patients decreased from 11.7 in 1999 to 3.2 in 2001 (P < .035)., Conclusions: This study demonstrated the rapid magnitude and significance that clinical programs can have upon referral bias. Changes in referral bias may be more rapid at rural academic medical centers because of the relative lack of health care delivery competition.

The effect of asymmetry on a person's lifting capacity was investigated using the psychophysical approach. Ten male college students lifted a box from pallet height (15 cm) to conveyor height (75 cm) at a frequency of one and five lifts/min. Three types of asymmetric lifting tasks (step-turn, middle twist and twist) were studied using 90 and 180 degrees task angles. Lifting capacity reductions for middle twist and twist at a 90 degrees asymmetric angle were about one-half of the 30% reduction that would be calculated by the 1991 National Institute for Occupational Safety & Health (NIOSH) lifting equation. The lifting capacity reduction for step-turn at 180 degrees was 14.9%, although that reduction cannot be calculated in the NIOSH equation. The middle twist lifting capacity was greatest among the three types at a 90 degrees task angle. The reductions for the middle twist and step-turn were not proportional to the task angle. This is contrary to the proportional reduction in the NIOSH lifting equation. Heart rate did not increase with an increase in task angle. Based on the results of this research, a different approach to assigning the asymmetric multiplier is proposed. This approach includes a task angle (as opposed to asymmetric angle) of up to 180 degrees.

DNA allows for the unambiguous identification of the person from whom a biological sample was derived but provides little information about when the sample was deposited. This information only indicated that the biological material was deposited at the crime scene prior to the collection of evidence. The ability to determine the age of a biological sample would greatly benefit the forensic science community. If there were independent evidence that the biological sample was deposited at the time of the crime, then its age would reveal when the crime occurred. If the time of the crime were known through another means, then the age of the biological sample could potentially exclude the human source as a suspect. We have used real-time reverse transcriptase PCR to show that the ratio between different types of RNA (mRNA versus rRNA) changes over time in a linear fashion when dried human blood from eight individuals was examined over the course of 150 days. Although other approaches have been used in the past to estimate the age of a biological sample, our approach offers the following advantages: enhanced detectability of small samples, simultaneous isolation of DNA and RNA from the same sample, species-specific probes, and an increased window of usefulness.

Study Objective: To determine whether daily high-dose vitamin C alters the steady-state pharmacokinetics of indinavir, a protease inhibitor indicated for treatment of the human immunodeficiency virus type 1., Design: Prospective, open-label, longitudinal, two-period time series., Setting: University medical center., Subjects: Seven healthy volunteers., Intervention: Indinavir 800 mg every 8 hours was given to subjects for four doses on days 1 and 2. Plasma samples were then collected for indinavir pharmacokinetic determination. After a 7-day washout period, subjects were given vitamin C 1000 mg/day for 7 days. Beginning on day 6 of vitamin C administration, indinavir 800 mg every 8 hours was restarted for four doses. Plasma was then collected from subjects to determine indinavir pharmacokinetics. All subjects were given a vitamin C content-controlled diet for 1 week before the study began and throughout the study period., Measurements and Main Results: Steady-state plasma samples were collected before dosing (0 hr) and 0.5, 1, 2, 3, 4, and 5 hours after dosing to determine indinavir pharmacokinetics. Parameters of interest were maximum plasma concentration (C max ), time to C max , area under the plasma concentration-time curve from 0-5 hours after the dose (AUC 0-5 ), an extrapolated 8-hour AUC (AUC 0-8 ), trough (minimum) plasma concentration (C min ), and oral clearance. Mean steady-state indinavir C max was significantly reduced (20%) after 7 days of vitamin C administration (10.3 +/- 1.5 vs 8.2 +/- 2.9 microg/ml, p=0.04). The corresponding mean AUC 0-8 was also significantly decreased (14%; 26.4 +/- 7.2 vs 22.7 +/- 8.1 microg*hr/ml, p=0.05). Although not statistically significant, the mean indinavir C min was 32% lower in the presence of vitamin C (0.27 +/- 0.17 C vs 0.18 +/- 0.08 microg/ml, p=0.09). Indinavir oral clearance and half-life were not significantly different., Conclusion: Concomitant administration of high doses of vitamin C can reduce steady-state indinavir plasma concentrations. Subtherapeutic concentrations of antiretroviral agents have been associated with viral resistance and regimen failure, but the clinical significance of our findings remains to be established.

No variant of multiple endocrine neoplasia type 1 (MEN1) has been reproducible among families. We examined two large kindreds with MEN1 variants, and we compared these to past reports. The two kindreds were followed up for 20-30 yr with MEN1 tumors in 30 members. Results in cases from two kindreds were that 93% showed parathyroid adenoma, 40% pituitary tumor (always prolactinoma), and 27% enteropancreatic endocrine tumor. The latter included 10% insulinoma, 7% nonfunctioning islet tumor, but only 10% gastrinoma. Compared with prior large series, this lower prevalence of gastrinoma (10% vs. 42%, P < 0.01) and higher prevalence of prolactinoma (40% vs. 22%, P < 0.01) define this variant. Many possible biases of retrospective analyses were excluded as possible explanations. Previously sequenced DNA showed no characteristic MEN1 mutation in these two kindreds and in a third, reported previously; the lack of any shared MEN1 mutation also excluded common ancestry for MEN1 among the three kindreds. The causes for differences between this variant and typical MEN1 are unknown. In conclusion, this variant shows more frequent prolactinoma and less frequent gastrinoma than typical MEN1; the variant is reproducible among kindreds. MEN1 carriers in such families should have periodic monitoring adjusted for the expected penetrance of tumors.

Background: Peroxynitrite is a toxic compound formed during the inactivation of nitric oxide (NO) by the superoxide anion. The physiologic significance of this pathway of NO metabolism has never been documented in vivo. Because peroxynitrite provides a pathway for the inactivation of NO we postulated that peroxynitrite's correlation with physiologic parameters would be the opposite of those associated with NO, which is a vasodilator and suppresses sudomotor function. We assessed the significance of peroxynitrite by comparing its associations with blood pressure (BP) and sudomotor responses with those of NO., Methods: Thirty-seven patients with type 1 diabetes enrolled in a longitudinal study of oxidative stress. Nitric oxide was assessed from nitrite and nitrate (collectively NOx) and peroxynitrite was assessed from the nitrotyrosine (nTy) content of protein., Methods: nTy was 13.3 +/- 2.0 micromol/L in the control subjects and 26.8 +/- 4.4 micromol/L, 26.1 +/- 4.3 micromol/L, and 32.7 +/- 4.3 micromol/L in the diabetic patients (P <.01) at the time of the first, second, and third evaluations, respectively. Patients with increased nitrotyrosine/tyrosine (nTy/Ty) had higher mean BP than those with low nTy/Ty (81.1 +/- l.9 mm Hg v 75.5 +/- 1.7 at the third evaluation, P <.025). The ratio of nTy/NOx correlated with BP at the first (P <.05), second (P <.05), and third (P <.01) evaluations. Patients with high nTy/Ty had increased sudomotor responses (5.85 +/- 0.75 microL of total sweat) at the third evaluation compared to those with low nTy/Ty (3.32 +/- 0.43 microL, P <.005) and normal controls (3.90 +/- 0.41 microL, P <.05). The associations of nTy with BP and sudomotor responses were the opposite of those with NOx., Conclusions: The conversion of NO oxide to peroxynitrite is physiologically significant in humans.

Background: Nurse job dissatisfaction has been the primary predictor of intent to leave; however, although many predictors of job satisfaction have been identified, little is known about the influence of variable nurse attitudes, such as psychological empowerment and hardiness, on job satisfaction., Objective: The purpose of this study was to investigate the relative influence of nurse attitudes, context of care, and structure of care on job satisfaction and intent to leave., Methods: A nonexperimental, predictive design evaluated these relationships in a nonrandom sample of 90 registered staff nurses using instruments with known psychometric properties., Results: The major predictor of intent to leave was job dissatisfaction, and the major predictor of job satisfaction was psychological empowerment. Predictors of psychological empowerment were hardiness, transformational leadership style, nurse/physician collaboration, and group cohesion., Conclusions: Results supported the influence of nurse attitude on job satisfaction relative to other contributing factors.

A relationship between antecedent trauma and amyotrophic lateral sclerosis (ALS) has been clinically suspected for over a century. Nine cases of ALS that occurred over a 14-year period in young U.S. men (age range, 28-43 years) following trauma that produced motor axonal injury that antedated (range, 5-42 months) the onset of ALS have been reported by a single neurologist. After estimating the number of cases of ALS in 28- to 43-year-old American men that would be expected to occur over a 14-year period, a reverse probability analysis technique was used to determine the expected incidence rates of motor axonal injury in a ideally matched control population that would give probabilities of 0.05, 0.01, and 0.001 of observing nine or more instances of motor axonal injury occurring during the previous 5 to 42 months. This analysis was repeated assuming that this one neurologist had only reported 50 and 10% of all instances of ALS that occurred during this 14-year period in American men ages 28 to 43 years who had experienced trauma that produced motor axonal injury that occurred 5 to 42 months before the onset of ALS. Reverse probability analysis is a technique that can be used in performing risk assessments.

The objective of this study was to examine the influence of frequent emergency department (ED) use on early returns to the ED at a large rural academic medical center. An analysis was done of all 35,440 visits by 22,442 individuals to a large rural academic medical center ED during calendar year 2000. Of 35,440 ED visits, there were 1,992 (5.62%) return visits within 72 hours (early return). Frequent ED visits (visits made by individuals making 4 or more visits per year) was a predictor of early return visits (odds ratio [OR] 3.21, 95% confidence interval [CI] 2.93-3.52; Wald chi(2), P <.0001). Of 22,442 individuals who came to the ED during the study period, 1,601 (7.13%) returned within 72 hours. Frequency of ED use by a particular individual (4 or more visits per year) was also a predictor of early return for that individual (OR 14.55, 95% CI 12.84-16.48; Wald chi(2), P <.000001). The high rate of early returns to this rural academic ED was significantly associated with frequent visits (4 or more times per year) to the ED by particular individual., (Copyright 2003, Elsevier Science (USA). All rights reserved.))

This study assessed the efficacy and safety of a nicotine sublingual tablet in smoking cessation in a randomized, double-blind, placebo-controlled outpatient trial conducted between January 1996 and May 1997. Two hundred and forty-one adult smokers (> or = 10 cigarettes/day for at least 3 years) used nicotine 2-mg sublingual tablet (n = 120) or placebo (n = 121) for up to 6 months (a 3-month treatment period followed by a 3-month tapering period). Subjects who scored <7 on the Fagerström Tolerance Questionnaire used 1 tablet/h (up to maximum of 20/day), whereas subjects who scored (7 used 2 tablets/h (up to maximum of 40/day). Brief counseling was provided at baseline and at all visits. Self-reported abstinence was measured from week 2 onwards, confirmed by expired carbon monoxide (CO) levels <10 ppm at each visit (1, 2, 3 and 6 weeks and 3, 6 and 12 months). After 6 weeks of treatment, CO-validated abstinence rates were 48% in the active group and 23% in the placebo group (p < 0.0001). At the 3-, 6- and 12-month visits, abstinence rates (active vs. placebo) were 33% vs. 17% (p = 0.0046), 21% vs. 11% (p = 0.0304) and 18% vs. 10% (p = 0.0606). Adverse events were mild and transient and reflected those reported with existing nicotine replacement formulations. We concluded that the nicotine 2-mg sublingual tablet was effective as a smoking cessation aid.

The present study was performed to determine whether nitric oxide overproduction is associated with deterioration in peripheral nerve function in type 1 diabetes. We measured peripheral nerve function and biochemical indicators of nitrosative stress annually for 3 years in 37 patients with type 1 diabetes. Plasma nitrite and nitrate (collectively NO(x)) were 34.0 +/- 4.9 micro mol/l in the control subjects and 52.4 +/- 5.1, 50.0 +/- 5.1, and 49.0 +/- 5.2 in the diabetic patients at the first, second, and third evaluations, respectively (P < 0.01). Nitrotyrosine (NTY) was 13.3 +/- 2.0 micro mol/l in the control subjects and 26.8 +/- 4.4, 26.1 +/- 4.3, and 32.7 +/- 4.3 in the diabetic patients (P < 0.01). Uric acid was suppressed by 20% in the diabetic patients (P < 0.001). Composite motor nerve conduction velocity for the median, ulnar, and peroneal nerves was decreased in patients with high versus low NTY (mean Z score -0.522 +/- 0.25 versus 0.273 +/- 0.22; P < 0.025). Patients with high NO(x) had decreased sweating, and those with suppressed uric acid had decreased autonomic function. In conclusion, nitrosative stress in early diabetes is associated with suppressed uric acid and deterioration in peripheral nerve function.

A chart review of acute stroke (DRG 14) discharges from a rural academic medical center in 1999 was performed because of an observed high in-hospital crude acute stroke mortality rate. An analysis of the results of this chart review demonstrated that the odds ratio of intracerebral hemorrhage in patients who had been transferred from other hospitals was 11.7 compared to intracerebral hemorrhage in nonhospital transfer patients (p < 0.00001). This finding illustrates the potential magnitude and significance of referral bias at a rural academic medical center.

Purpose: To evaluate the impact of implementing a hospitalist service with a nurse discharge planner in an academic teaching hospital., Subjects and Methods: Inpatient medicine service was provided by hospitalists, general internists, and specialists. Service personnel were identical except that the hospitalist service also had a nurse discharge planner. Hospitalists attended 4 months per year (compared with the 1 month by most other attending physicians) and had no outpatient responsibilities during the ward months. Patients were admitted alternately based on resident call schedule. Major outcomes included average costs of hospitalization, length of stay, and resource utilization. Quality measures included inpatient mortality, 30-day readmission rates, and satisfaction of patients, residents and students., Results: Hospitalist-attended services had lower mean (+/- SD) inpatient costs per patient ($4289 +/- $6512) compared with specialist-staffed services ($6066 +/- $7550, P < 0.0001), with a trend toward lower costs when compared with generalist-attended services ($4850 +/- $7027, P = 0.11). Hospitalist services had shorter mean lengths of stay (4.4 +/- 4.0 days), compared with generalists (5.2 +/- 5.2 days) and specialists (6.0 +/- 5.5 days, P < 0.0001 for hospitalists vs. both groups). Readmission rates were similar in all groups. Mortality rates were higher in the specialist group [5.0% (44 of 874)] compared with hospitalists [2.2% (18 of 829)] and generalists [2.6% (20 of 761), P = 0.002 for specialists vs. both groups, P = 0.09 for generalists vs hospitalists]. Satisfaction results were uniformly high in all groups, with no significant differences., Conclusion: Hospitalist services with a nurse discharge planner were associated with lower average cost and shorter average length of hospital stay, without any apparent compromise in clinical outcomes or patient satisfaction.

A meta-analysis of five published case-control studies that examined the association between previous blood transfusions and Creutzfeld-Jakob disease was performed. The results demonstrated that controls were more likely (p < 0.001, odds ratio = 1.56, 95% confidence interval, 1.22-1.98) to have received previous blood transfusions (18.7%) than Creutzfeld-Jakob disease patients (12.9%), suggesting that selection bias of the control populations had occurred.

Objectives: To evaluate the predictive accuracy as well as the rates of false-positive and false-negative results of CT and positron emission tomography (PET)-fluorodeoxyglucose (FDG) imaging in detecting the metastatic intrathoracic lymph nodes in patients with suspected or proven non-small cell lung cancer (NSCLC). Our other objective was to determine the need for routine invasive sampling procedure in confirming PET/CT staging results., Methods: The results of CT and PET-FDG scanning in 77 patients with suspected or proven NSCLC were correlated with the histologic findings of hilar/mediastinal lymph node sampling using mediastinoscopy, open biopsy, thoracotomy, or thoracotomy with resection. Patients were then classified into resectable and unresectable groups based initially on PET results and compared to histologic findings., Results: The sensitivity, specificity, and accuracy of CT and PET for detecting metastatic lymphadenopathy were 68%, 61%, 63%, and 87%, 91%, and 82%, respectively. A change of management with routine sampling following PET was seen in five of six patients (83%) with false-positive findings (13%) but in none of four patients (9%) with false-negative findings., Conclusion: The false-positive findings of PET-FDG imaging affected selection of treatment in 83% of patients. However, false-negative results did not change management in any patient. This could potentially prevent unnecessary invasive thoracotomy, mediastinoscopy, or other sampling procedures in patients with negative PET results.

Patients with diabetic neuropathy typically have decreased sweating in the feet but excessive sweating in the upper body. Previous studies of sudomotor function in diabetes have included patients with longstanding disease. The present study was designed to test for the early presence of sudomotor dysfunction and to characterize its relation to glycemic control and other aspects of peripheral nerve function. A total of 37 patients (10 males, 27 females) enrolled in a longitudinal study, in which autonomic function was evaluated annually for 3 years. Patients enrolled 2-22 months after the diagnosis of type 1 diabetes. Forty-one age- and sex-matched healthy control subjects were also studied. Sweat production in response to acetylcholine stimulation was dramatically increased in the forearm at the time of the first evaluation (1.67 +/- 0.24 micro/cm2 in the diabetic patients vs. 1.04 +/- 0.14 microl/cm2 in the control subjects, P < 0.05). Likewise, the ratio of sweating in the forearm to sweating below the waist was higher in the diabetic patients (0.553 +/- 0.07 microl/cm2) than in the control subjects (0.385 +/- 0.04 microl/cm2, P < 0.05). Forearm sweat was negatively associated with the renin-toprorenin ratio and vanillylmandelic acid (VMA) excretion (P < 0.025), tests of sympathetic nerve function. The ratio of sweating in the forearm to sweating in the foot was likewise increased in diabetic patients with poor glycemic control. We interpret this redistribution of sudomotor responses to be indicative of sympathetic nerve injury and conclude 1) that the sympathetic nervous system is especially vulnerable to the adverse effects of chronic hyperglycemia and 2) that sympathetic dysfunction can be detected very early in type 1 diabetes.

Autoimmune mechanisms have been implicated in the pathophysiology of diabetic neuropathy. We studied the association between glutamic acid decarboxylase (GAD65) and islet cell (IA-2) autoantibodies as well as autoantibodies to the autonomic nervous system and peripheral nerve function in recent onset type 1 diabetes. Thirty-seven patients (27 females and 10 males) enrolled 2-22 months after diagnosis. Humoral factors, glycemic control, and peripheral nerve function were measured annually for 3 yr. Patients with high GAD65Ab had worse glycemic control and higher insulin requirements. Patients with high GAD65Ab had slower motor nerve conduction velocities in the median, ulnar, and peroneal nerves (P < 0.025 for each nerve). The mean motor nerve conduction velocity Z scores at the time of the third evaluation was 0.341 +/- 0.25 for the low GAD65Ab patients and -0.600 +/- 0.25 for the high GAD65Ab patients (P < 0.01). Similar differences between the low and high GAD65Ab groups were observed for F wave latencies, thermal threshold detection, and cardiovascular autonomic function. The composite peripheral nerve function Z scores in the low GAD65Ab patients were 0.62 +/- 11, 0.71 +/- 0.19, and 0.21 +/- 0.14 at the first, second, and third evaluations, significantly different from those in the high GAD65Ab patients in whom they were -0.35 +/- 0.15, -0.46 +/- 0.18, and -0.42 +/- 0.16 (P < 0.001). In summary, GAD65Ab in patients with recent onset type 1 diabetes are associated with worse glycemic control and slightly worse peripheral nerve function. Although the latter remained within normal limits and none of the patients had clinical neuropathy, the GAD65Ab-related differences in composite peripheral nerve function were highly significant (P < 0.001) and could not be attributed to GAD65Ab-related differences in glycemic control.

It is well documented that diabetic patients with chronic complications have decreased renin secretion and elevations in the renin precursor prorenin. It is uncertain, however, whether the abnormal processing of prorenin is reflective of microvascular disease, hypertension, or autonomic neuropathy. Dechaux et al. (Transplant Proc. 18:1598-1599, 1986) observed abnormalities in prorenin processing in uncomplicated diabetes and suggested that it was the result of subclinical autonomic neuropathy. To test this hypothesis, we measured renin, prorenin, and autonomic function in early type 1 diabetes at a time when there is little or no microvascular disease or hypervolemia. Thirty-seven patients (10 males, 27 females) enrolled 2-22 months after diagnosis in a longitudinal study in which renin, prorenin, and autonomic function were measured annually for 3 years. Forty-one age-matched control subjects were also studied. PRA in the diabetic patients at the time of the second and third evaluations was 1.71 +/- 0.24 ng angiotensin I/mL x h and 1.67 +/- 0.24 ng angiotensin I/mL x h, respectively, significantly lower (P < 0.05) than that of the control subjects in whom PRA was 2.96 +/- 0.38 ng angiotensin I/mL x h. Prorenin was not different in the diabetic patients in comparison with controls. The renin to prorenin ratio in the diabetic patients at the time of the first, second, and third evaluations was 0.260 +/- 0.03, 0.235 +/- 0.05, and 0.227 0.05, respectively, significantly lower (P < 0.01) than in control subjects in whom the renin to prorenin ratio was 0.475 +/- 0.08. Despite this, at the time of the first and second evaluations, there was no evidence of autonomic dysfunction and no correlation between any test of autonomic function and the renin to prorenin ratio. At the time of the third evaluation, however, the intermediate frequency (0.04-0.15 Hz) power spectra while patients were supine (an index of sympathetic modulation of heart rate variability) showed a highly significant (P < .001) correlation with the renin to prorenin ratio. High frequency (0.15-0.40 Hz) spectra from supine patients at the third evaluation also correlated with the renin to prorenin ratio (P < 0.01). We conclude abnormal processing of prorenin develops in diabetic patients prior to microvascular disease, even before the first evidence of autonomic dysfunction. Although the latter may play a contributory role, additional as yet unidentified mechanisms seem to interrupt the processing of prorenin in early diabetes.

This article reports the psychophysical assessment of nine battery-powered lifts, a sliding board, a walking belt, and a baseline manual method for transferring nursing home patients/residents from a bed to a chair. A separate article reports the biomechanical evaluation of the same task and devices. The objectives of the psychophysical assessment were to investigate the effects of resident-transferring methods on the psychophysical stress to nursing assistants performing the transferring task, and to identify transfer methods that could reduce the psychophysical stress reported by nursing assistants. Nine nursing assistants served as test subjects. Two elderly persons participated as residents. The results indicated that the psychophysical stresses on nursing assistants were significantly lower when performing resident transfers with some of the assistive devices than when performing transfers with the baseline manual transfer method. The nursing assistants generally preferred the basket-sling lift and stand-up lift to other methods. The residents' comfort and security ratings indicated the comfort and security with most of the assistive devices were greater than or equal to the baseline manual method. Most of the comments of the nursing assistants and residents on the assistive devices were favourable.

Respiration and suck are gestational age-dependent reflexes modulated in the brain stem. To determine if the suck reflex pattern could be used to predict apnea, the relationship between the two was examined in 28 neonates. The suck reflex was quantified with respect to burst-pause rhythm, amplitude of negative suck pressure, and synchrony of the negative-positive pressure. Apneas were counted 5 days prior to and following measurement of the suck reflex pattern. Increasing gestational age correlated with a lower frequency of apnea (P < .01) and higher suck scores (P < .01). A mature suck reflex pattern, however, failed to predict the occurrence of apnea.

Background: The role of prophylactic antibiotics (PABs) in preventing infections associated with intracranial pressure (ICP) monitors and external ventricular drains (EVD) is not well defined., Methods: This study includes an analysis of published reports and a survey of current practices regarding the use of PABs with ICP monitors and EVDs. A computerized data search and a review of the abstracts from two major national neurosurgical meetings over the past decade yielded 85 related articles. Three independent investigators, blinded to the title, author(s), institution(s), results, and conclusions of the articles used predetermined inclusion criteria to select studies for meta-analysis. Thirty-six responses were returned from 98 questionnaires (37%) mailed to university neurosurgical programs., Results: Among the articles reviewed, only two studies met the predetermined inclusion criteria for the meta-analysis, and they were of insufficient size to produce statistically significant results. Among the 36 programs that responded to the survey, 26 (72%) used PABs, mainly cephalosporins (46%) and semisynthetic penicillins (38%), with ICP monitors and EVDs. Twenty-two (85%) used one drug, and 4 (15%) used two drugs. Twenty-two (61%) of the total group reported intra-institutional variation in practices among individual staff neurosurgeons. Nineteen (53%) expressed interest in a retrospective study, and 27 (75%) expressed interest in a prospective study on the role of PABs in minor neurosurgical procedures., Conclusion: No consensus regarding the use of PABs with ICP monitors and EVDs is noted. Randomized controlled trials of sufficiently large size with appropriate blinding are needed to address this issue.

This is the first of two articles to report a biomechanical evaluation and psychophysical assessment of nine battery-powered lifts, a sliding board, a walking belt, and a baseline manual method for transferring nursing home residents from a bed to a chair. The objectives of the biomechanical evaluation were: (1) to investigate the effects of transfer method and resident weight on the biomechanical stress to nursing assistants performing the transferring task, and (2) to identify resident-transferring methods that could reduce the biomechanical stress to the nursing assistants. Nine nursing assistants served as test subjects; two elderly persons participated as residents. A four-camera motion analysis system, two force platforms, and a three-dimensional biomechanical model were used to measure biomechanical load. The results indicate that transfer method and resident weight affect a nursing assistant's low-back loading. The basket-sling and overhead lift devices significantly reduced the nursing assistants' back-compressive forces during the preparation phase of a resident transfer. In addition, the use of basket-sling, overhead, and stand-up lifts removed about two-thirds of the exposure to low-back stress (lifting activities per transfer) as compared to the baseline manual method. Thus, the use of these devices reduces biomechanical stress, and thereby will decrease the occurrence of resident-handling-related low-back injuries. Furthermore, lifting device maneuvering forces were found to be significantly different and a number of design/use problems were identified with various assistive devices. The second article will detail the psychophysical assessment of the same resident-transferring methods.

To obtain an estimate of prostate cancer prevalence when screening is applied to a workforce, we conducted a search of the English world literature from West Virginia University. Thirty-one papers which met selection criteria for screening were followed by histopathologic diagnosis. Publications using Prostate Specific Antigen (PSA) as a screening test were reviewed. The data from these papers were combined. Population characteristics were then selected to represent the demographics of a working population. Prostate cancer prevalence estimates for the demographics of a working population were calculated using a weighted mean after relevant studies lacked homogeneity and therefore failed meta-analysis. The expected prevalence of prostate cancer in a workplace surveillance population is 2.03% (95% C.I. from 1.69% to 2.37%). This information is useful to entities considering workplace surveillance. Selection bias, geographic location, and uncertainty in prediction of a representative workforce population may strongly influence estimates.

Objective: To examine the influence of gestational age on seizures in the neonatal intensive care unit., Study Design: A cohort of 4165 neonates admitted to a university intensive care unit between 1986 and 1995. The incidence, time of onset, and etiology of neonatal seizures in the cohort were distributed by gestational age. Logistic regression and t test were used to examine the relationship between gestational age and seizures in the neonatal intensive care unit., Results: Seizures occurred in 356 (8.6%) infants. The seizure rate was parabolically related to gestational age, such that infants at 30 to 36 weeks' gestation had a 4.8% rate compared with 11.9% and 14.1% rates for infants < 30 and > 36 weeks, respectively (p < 0.001). Seizures manifested earlier in infants < 30 weeks (2.3 +/- 5.6 days of life) and > 36 weeks (3.7 +/- 8.7 days) gestational age compared with neonates 30 to 36 weeks (10.4 +/- 14.5 days) (p < 0.001). Intraventricular hemorrhage was the principal etiology underlying the higher seizure rate for infants < 30 weeks (p < 0.001). Hypoxic-ischemic encephalopathy and congenital malformations were primary factors for infants > 36 weeks (p < 0.01). Nervous system infections were evenly distributed across gestational age., Conclusion: Gestational age exerts a considerable influence on the incidence, onset, and etiology of neonatal seizures.

Objectives: Our purpose was to test the hypothesis that the acute pressure natriuresis curve was reset in pregnancy to facilitate the volume expansion., Study Design: Studies were done with 14- to 16-day pregnant (n = 8) and age-matched virgin female (n = 6) Sprague-Dawley rats that were under general anesthesia. The left kidney was denervated, and mechanical clamps were placed on the aorta above and below the renal arteries for manipulation of renal perfusion pressure. Rats received intravenous 0.9% sodium chloride (1.5% body weight/h) and a cocktail of vasoactive factors to suppress variation in endogenous hormones. Renal perfusion pressure was varied acutely from 125 to 95 mm Hg, and glomerular filtration rate, renal plasma flow, sodium excretion, and urine flow were measured in both kidneys at each renal perfusion pressure. Data were analyzed by unpaired t test and by homogeneity by slopes., Results: The acute pressure natriuresis curve was blunted in pregnant rats versus virgins, and the renal nerves were not responsible. The blunted natriuretic response in pregnancy was due to loss of tubular epithelial responsiveness to increased blood pressure., Conclusion: The pressure natriuretic response is markedly blunted in pregnancy, permitting the cumulative plasma volume expansion to occur. Contrary to nongravid states, blunting of the acute pressure natriuresis curve in pregnancy is not associated with increased blood pressure because of the profound peripheral vasodilation. This suggests an alteration in the mechanism(s) normally linking blood pressure control to the acute pressure natriuresis relationship.

The significance of intersections in age-specific mortality rate distributions could be attributed to a fundamental statistical relationship between estimates of slope and intercept. A strong negative correlation between estimates of slope and intercept is often observed in simple linear regression problems. The net result is that the family of lines generated by repetitive estimates of slope and intercept in a static experimental situation will tend to intersect at a common point. This statistical relationship between slope and intercept, however, should be random with respect to the time-ordered sequence of slope and intercept estimates. Annual paired slope and intercept estimates derived using the method of longitudinal Gompertzian analysis of age-specific mortality rates for men and women in the United States from 1900 to 1988 were analyzed to determine if they varied randomly. The probability that the observed sequence in these annual paired slope-intercept estimates was random is less than 10(-50) for both men and women. This finding essentially excludes the possibility that intersections in age-specific mortality rate distributions reflect a fundamental statistical relationship between slope and intercept and further suggests biological relevance for the method of longitudinal Gompertzian analysis.

The purpose of this study was to compare two treatments for orthostatic hypotension, midodrine (an alpha adrenergic agonist), and octreotide (an SRIH analogue) to each other and to combination therapy. Sixteen patients participated. Our hypothesis was that the 2 drugs together would be more effective than either drug alone. The effect of the drugs on the hemodynamic response to food ingestion was evaluated while patients were sitting. Midodrine (5 mg orally, 30 min before breakfast) increased mean blood pressure slightly (5-10 mm Hg, over 30 min) before the patients started eating, but it only partially reversed the hypotensive effect of food ingestion. The nadir in postprandial blood pressure after midodrine was 69 +/- 4 mm Hg, not different from placebo (63 +/- 5). Nevertheless, midodrine accentuated the response to sc octreotide (0.5 microgram/kg). Fifteen minutes after octreotide administration to midodrine-pretreated patients, the average mean blood pressure was 115 +/- 9 mm Hg, higher (P = .0095) than after octreotide given alone (102 +/- 7). Drug effects on orthostatic hypotension were assessed by measuring standing time (minutes before symptoms of hypotension or definite hypotension). In the absence of treatment, standing time was 3.5 +/- 7 min; 1 h after 10 mg midodrine, 8.4 +/- 2.7 min (P = .11); after 1.0 microgram/kg octreotide, 13.2 +/- 3.9 min (P = .0034 vs. no treatment); and after both drugs, 21.2 +/- 5.5 min (P = .0002 vs. no treatment, P = .036 vs. octreotide only). The combination of midodrine and octreotide is more potent than either drug alone.

Objective: To analyze the effect of antibodies to glutamic acid decarboxylase (GAD65Ab) and islet cells (ICA512Ab) on glycemic control early in IDDM., Research Design and Methods: GAD65Ab and ICA512Ab were measured twice in 35 patients (10 male, 25 female; age 10-40 years) initially within 2 years of diagnosis and again 1 year later. The glycosylated hemoglobin was measured one to four times each year, and the average glycosylated hemoglobin for the preceding year was calculated each time the antibodies were measured., Results: The mean HbA1 at the time of the initial evaluation was 8.04 +/- 0.30 (reference range 4.7-7.3% for nondiabetic patients), the average GAD65Ab index was 0.735 +/- 0.306, and the mean ICA512Ab index was 1.94 +/- 0.65. The GAD65Ab index correlated with HbA1 (r = 0.41, P < 0.025), whereas the ICA512Ab index did not (r = 0.13). One year later, the mean GAD65Ab index was 0.94 +/- 0.34, the mean ICA512Ab index was 1.04 +/- 0.40, and the mean HbA1 was 9.03 +/- 0.30. The GAD65Ab index correlated with HbA1 (r = 0.61 P < 0.001), whereas the ICA512Ab index did not (r = -0.06). Stratification of patients into tertiles according to the average GAD65 index revealed, at the follow-up evaluation, that the better glycemic control in the lowest GAD65Ab tertile was accomplished with significantly less insulin (0.43 +/- 0.08 U/kg for the lowest tertile vs. 0.71 +/- 0.09 and 0.64 +/- 0.09 for the middle and highest tertiles, respectively; P < 0.05)., Conclusions: In summary, patients with IDDM and low GAD65Ab have better glycemic control even though they require less insulin. The ICA512Ab index, however, fails to correlate with glycemia.

Violence in the United States has reached epidemic proportions. Homicide rates are a frequently used measure of societal violence. The dynamics of age-specific homicide rates among men and women in the United States from 1951 to 1990 were examined. In contrast to men of other age groups and women of all age groups, annual changes in homicide rates among men in the 15- to 54-year-old age groups were synchronous. Although homicide is a complex expression of human aggression with a multitude of biological and sociocultural factors, this finding suggests that men of reproductive age experience simultaneous changes in sociocultural influences on the expression of violence.

Objective: Measure bone mineral density (BMD) in healthy Newfoundland adolescents and determine whether BMD is comparable in geographically diverse adolescent populations., Study Design: Lumbar spine BMD was measured by dual-energy radiograph absorptiometry in 26 healthy adolescents between ages 8 and 20 years. The age and gender of these subjects were used to predict BMD from equations derived from normative BMD data in six geographically diverse populations. The actual BMD value obtained for each subject was then compared with each of the six predicted BMD values for that adolescent using the Wilcoxon signed-ranks test., Results: Actual lumbar spine BMD in Newfoundland adolescents was not significantly different from that predicted by age and gender if they were from California, Finland, France, North Carolina, and Switzerland. Only the prediction based on the Spanish population resulted in a 4% greater BMD than was actually measured in the Newfoundland adolescents., Conclusions: Lumbar spine BMD measurements for most healthy adolescent populations, as in adults, are comparable despite geographic diversity. Thus, generation of institution-specific normative BMD data may not be necessary for most adolescent populations.

Thirty-one patients, aged 12.6 +/- 5.6 years, with refractory seizures for 8 +/- 4.3 years, were treated with adjunctive vigabatrin. Twenty-four percent had a > 50% reduction in seizure frequency (95% one-sided confidence interval). Generalized myoclonic, atonic, and tonic clonic and partial, with and without secondary generalization, seizures were all reduced at a mean dose of 70 +/- 38 mg/kg/day. Comparison of vigabatrin therapy duration, for partial and generalized seizure groups, utilizing Kaplan-Meier methodology showed similar survival times. Vigabatrin therapy was ineffective in the four children with tuberous sclerosis. Transient somnolence, ataxia and dizziness were the most frequent side effects. A severe aggressive agitation occurred in three patients, and necessitated discontinuation of vigabatrin in one patient. Vigabatrin was as effective in generalized as in partial seizures in this study. Clinical utility may be limited by unacceptable behavioral side effects in some patients.

It has been suggested that the size of the corpus callosum may have diagnostic significance in cerebral palsy, although this relationship is incompletely defined. Ninety-one patients with cerebral palsy had been studied by magnetic resonance imaging in the 5-year period from 1990 to 1994. Fifty-seven of these 91 patients had a technically appropriate midsagittal magnetic resonance image for quantitative morphometric analysis. The ratio of the area of the corpus callosum to the area of the supratentorial brain was compared to published age- and gender-specific norms. Imaging findings were correlated with clinical history and cause of cerebral palsy. The corpus callosum was of normal size in 43 patients and more than 2 standard deviations below the mean in 14 patients. The causes for cerebral palsy included hypoxic ischemic encephalopathy (32), cerebral dysgenesis (8), and porencephalic strokes (6); the etiology could not be established in 11 patients. The size of the corpus callosum was highly correlated with the cause of cerebral palsy, such that all patients with cerebral dysgenesis had hypoplasia of the corpus callosum (one-sided z test, p < 0.0001). Conversely, the callosum was of normal size in 32 of 38 patients with hypoxic ischemic encephalopathy and porencephalic strokes. The presence of a hypoplastic corpus callosum is highly associated with cerebral dysgenesis as a cause for cerebral palsy.

The incidence of sexually transmitted diseases in a primarily student-based patient population served by a university health service was reviewed because of the perception that the number of positive chlamydia tests was declining. The most striking finding that emerged was that there was, indeed, a persistent and steady decline in the rates of chlamydia infection over the study time period of 1989 to 1994. Other sexually transmitted diseases showed less definite declines or no significant change. The authors evaluated the number of positive chlamydia tests in the health service with symptoms suggestive of chlamydia infection. Of all university health service patients who tested positive for chlamydia, 48.8% were asymptomatic. A majority (75.2%) of the female patients who tested positive on their annual routine family-planning examination were also asymptomatic for chlamydia. Chlamydia-positive men presenting to the health service were far more likely to be symptomatic than were the women who were positive. Overall, a significant decrease in chlamydia occurred over the 5-year period in spite of an increasing enrollment, a fact that could perhaps be attributable to students' increased awareness of the risk of sexually transmitted infections and their use of condoms.