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OBJECTIVES: To compare dementia risks of elderly black and white subjects and to determine whether differences in education and cognitive test scores contribute to the inconsistency in reported differences between these groups. DESIGN: Longitudinal, 6-year follow-up. PARTICIPANTS: Two thousand seven hundred eighty-six older black and white subjects in the Cardiovascular Health Study. MEASUREMENTS: Age, education (>10 years vs ≤10 years), Modified Mini-Mental State Examination score (3MS, ≤85 vs >85). Potential confounders were sex, depression, apolipoprotein E4 genotype, vascular disease, and baseline magnetic resonance imaging changes. RESULTS: White subjects with low education and black subjects with high education had twice the risk of dementia of white subjects with high education (95% confidence interval (CI)=1.5–2.4 and 95% CI=1.4–2.7); black subjects with low education had five times the risk of dementia (95% CI=3.4–7.7). Likewise, for subjects with low 3MSE scores, black subjects had 6.7 times the risk of dementia (95% CI=4.7–9.7) and white subjects had 2.7 times the risk of dementia (95% CI=2.2–3.5) as white subjects with high 3MSE scores. Finally, in Cox models, there was no significant black-white difference in dementia risk after adjustment for all confounders and baseline 3MSE. CONCLUSION: Black race was associated with greater dementia risk even after adjustment for education and other potential confounders. This black-white difference in dementia risk was markedly attenuated after adjustment for baseline cognitive screening scores. The apparent race effect may reflect gaps in the quality of education or differences in the trajectory of impaired cognitive function experienced by the two groups. Future investigations might take these findings into consideration for the design of studies evaluating black-white differences in dementia risk.

Objective: The authors evaluated 3,375 participants without dementia at the time of MRI in 1991 to 1994 over 5.7 years for incident dementia and type of dementia. Methods: Incidence of and risk factors for vascular dementia (VaD) were measured using both pre-MRI and modified State of California Alzheimer9s Disease Diagnostic and Treatment Centers (ADDTC) post-MRI review and further classified Alzheimer disease (AD) by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer9s Disease and Related Disorders Association (NINCDS-ADRDA) criteria. Results: Approximately 44% (213) of 480 incident dementia cases were classified as possible or probable VaD by ADDTC. The incidence of VaD increased with age and was greater in blacks than whites. Risk factors for VaD included age, Modified Mini-Mental State Examination, high white matter grade, number of MRI infarcts, ventricular size, and history of stroke. Conclusions: Vascular disease in the brain is prevalent among incident dementia cases. There is a substantial overlap between cases classified as Alzheimer disease by Neurological and Communicative Disorders and Stroke and the Alzheimer9s Disease and Related Disorders Association and vascular dementia (VaD) by modified State of California Alzheimer9s Disease Diagnostic and Treatment Centers criteria. The substantial contribution of vascular disease would be missed without inclusion of MRI. Treatment of risk factors for VaD could have an important impact on incidence of dementia.

Objectives: To estimate the incidence and prevalence of dementia, Alzheimer's disease (AD), and vascular dementia (VaD) in the Cardiovascular Health Study (CHS) cohort. Design: Longitudinal cohort study using prospectively and retrospectively collected data to evaluate dementia. Setting: Four U.S. communities. Participants: There were 3,602 CHS participants, including 2,865 white and 492 African-American participants free of dementia, who completed a cranial magnetic resonance image between 1992 and 1994 and were followed for an average of 5.4 years. Measurements: Dementia was classified by neurologist/psychiatrist committee review using neuropsychological tests, neurological examinations, medical records, physician questionnaires, and proxy/informant interviews. Demographics and apolipoprotein E (APOE) genotype were collected at baseline. Incidence by type of dementia was determined using National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for AD and Alzheimer's Disease Diagnostic and Treatment Center's State of California criteria for VaD. Results: Classification resulted in 227 persons with prevalent dementia at entry into the study and 480 incident cases during follow-up. Incidence rates of dementia scaled to age 80 were 34.7 per 1,000 person-years for white women, 35.3 for white men, 58.8 for African-American women, and 53.0 for African-American men. Sex differences were not significant within race. Adjusted for age and education, racial differences were only of borderline significance and may have been influenced by ascertainment methodology. Rates differed substantially by educational attainment but were only significant for whites. Those with the APOE ɛ4 allele had an incidence rate at age 80 of 56.4, compared with 29.6 for those without this allele (P

Background: The Cardiovascular Health Cognition Study has evaluated the determinants of dementia among 3,608 participants that had a magnetic resonance imaging (MRI) of the brain in 1991 and were followed to 1998–1999. Methods: There were 480 incident dementia cases, 330 (69%) were classified as Alzheimer’s disease (AD). Results: In univariate analysis, low scores on the Modified Mini-Mental State Examination (3MSE) and on the Digit Symbol Substitution Test as well as declines in scores over time prior to the development of dementia were significant predictors of dementia. A high ventricular grade on the MRI (atrophy) as well as high white matter grade, a number of brain infarcts on the MRI were all determinants of dementia. Apolipoprotein E Ε4 (ApoE-4) was also a powerful predictor of dementia. In a multivariate Cox proportional hazards model controlling for race, gender and grade, the hazard ratios for age (1.1), 3MSE score (0.9), ventricular size (1.4), white matter grade (1.8), presence of large infarcts >3 mm (1.3) and ApoE-4 (2.1) were significant predictors of dementia. The combination of an ApoE-4 genotype, 3MSE score Conclusions: Measures of cognition, ApoE-4 and MRI of the brain are strong predictors of both dementia and of AD.

Purpose This is a prospective audit to determine the frequency of resuscitation interventions in the clinical setting and to compare self-reports of clinical performance with the existing Neonatal Resuscitation Program (NRP) and Canadian National Guidelines for Neonatal Resuscitation. Subjects Fifty-six level I, II, and III hospitals in Canada participated. Any infant requiring resuscitation, as defined by the need for at least positive pressure ventilation (PPV), was eligible for inclusion (n = 783 resuscitations). Design and methods A prospective self-report audit was chosen and data were collected over a 6-month period in 1998. The audit focused on the use of PPV, intubation, chest compressions, free-flow oxygen, or medications during the resuscitation. The infant's temperature at the end of resuscitation was also noted. The data were analyzed with descriptive statistics. The composition of the resuscitation team and their NRP certification status were recorded. Principal results The need for resuscitation was not anticipated in 76% of the cases (596 of 783). Errors in the sequencing of care, such as delays in initiating PPV, provision of chest compressions before or without establishing an airway and ventilatory support, and administering naloxone before PPV, were reported. Resuscitations attended by a team of NRP certified providers had improved sequencing when compared with those in which only some individual providers were certified. Chest compressions were provided in 8% of the cases (65 of 783). Medications were used in 14% (113/783) of all cases. Providers in level I hospitals performed chest compressions more frequently than those in level II and III settings. At the end of the resuscitation, 27% of the infants were hypothermic (142 of 520), and 25% were hyperthermic (128 of 520). Overall, 52% were out of the normal neutral range. Conclusions Clear differences between the NRP guidelines and actual clinical practice were shown. A high rate of unanticipated resuscitations, delivery room medications, and chest compressions was described. Postresuscitation hypothermia or hyperthermia were common. Improved sequencing was noted when the entire resuscitation team was NRP certified. Certification in NRP does not assure competency, nor does it ensure compliance with established standards of care.

Background: Silent infarcts are commonly discovered on cranial MRI in the elderly. Objective: To examine the association between risk of stroke and presence of silent infarcts, alone and in combination with other stroke risk factors. Methods: Participants (3,324) in the Cardiovascular Health Study (CHS) without a history of stroke underwent cranial MRI scans between 1992 and 1994. Silent infarcts were defined as focal lesions greater than 3 mm that were hyperintense on T2 images and, if subcortical, hypointense on T1 images. Incident strokes were identified and classified over an average follow-up of 4 years. The authors evaluated the risk of subsequent symptomatic stroke and how it was modified by other potential stroke risk factors among those with silent infarcts. Results: Approximately 28% of CHS participants had evidence of silent infarcts (n = 923). The incidence of stroke was 18.7 per 1,000 person-years in those with silent infarcts (n = 67) compared with 9.5 per 1,000 person-years in the absence of silent infarcts. The adjusted relative risk of incident stroke increased with multiple (more than one) silent infarcts (hazard ratio 1.9 [1.2 to 2.8]). Higher values of diastolic and systolic blood pressure, common and internal carotid wall thickness, and the presence of atrial fibrillation were associated with an increased risk of strokes in those with silent infarcts (n = 53 strokes). Conclusion: The presence of silent cerebral infarcts on MRI is an independent predictor of the risk of symptomatic stroke over a 4-year follow- up in older individuals without a clinical history of stroke.

Objective: To determine the prevalence and population attributable risk PAR of sociodemographic and lifestyle risk factors for delivery of premature babies among women giving birth to a single baby and living in Ottawa-Carleton, Canada. Methods: A population-based survey was conducted with a self-administered questionnaire which was completed by women in the immediate postpartum period in hospital. Women who did not complete the questionnaire at that time were followed-up by mail and phone. Women who refused the long questionnaire were asked to complete a short version. Logistic regression analysis was used to identify factors associated with Preterm birth. Adjusted PARs were calculated to examine the contribution of individual risk factors controlling for other selected factors. Results: The full questionnaire was completed by 7940 women (81.7%) and 512 completed a shorter version (5.3%). Key risk factors, identified via logistic regression, were then used to calculate population attributable risk percent. The factors contributing most to preterm birth as calculated by the population attributable risk percent when adjusting for other factors were: primiparity (37.0%), presence of a serious health problem (14.2%), high perceived stress during pregnancy (14.0%), previous preterm birth (13.1%), smoking after the fourth month (9%) short maternal height (6.6%), and previous abortion (5.5%). Conclusion: Understanding the relative contribution of possible modifiable and non-modifiable factors that are associated with preterm birth in a specific population is an important step in the design of prevention strategies. However, preterm prevention programs should not rely on lifestyle modification alone, as these factors make only a modest contribution to the overall population attributable risk for preterm birth.

Reported residential fungal contamination has been associated consistently with increased symptoms among occupants; however, an objective measure of a health effect is lacking, and a pathophysiologic mechanism has not been established. Our objective was to determine if exposure to indoor fungal contamination influenced T-cell differentiation. In this study, we contrasted lymphocyte populations, measured by flow cytometry, between a group of children who lived in homes with considerable fungal contamination (n = 39) and a group in less-contaminated homes (n = 20). Indicators of fungal biomass were viable fungi in house dust and air ergosterol in the child's bedroom. Living in a more-contaminated home versus a less-contaminated home was associated with a larger number of CD3+ T cells expressing CD45RO (1.5 x 10(9)/I versus 1.1 x 10(9)/I, respectively; p = .05, two-tailed t testing) and a reduced CD4/CD8 ratio (1.6 versus 1.8, respectively; p = .04). The differences persisted over a 12-mo period, and they were not explained by the child's age or total serum IgE, dust mite antigens, and the presence of furry or feathered pets or a humidifier. The results suggest that residential fungal contamination leads to chronic stimulation of children's lymphocytes.

In 2 experiments, the effect of active or passive mobility and active or passive choice experiences on children's memory for locations visited while retrieving puzzle pieces hidden in a large room were examined. In the first experiment, fifty-two 6- and 7-year-old children were randomly assigned to 1 of 4 training conditions: active choice-active movement, active choice-passive movement, passive choice-active movement, and passive choice-passive movement. After 3 training trials, all children were tested in the active choice-active movement condition. A 2 (movement) x 2 (choice) factorial multivariate analysis of variance revealed a significant main effect for movement. Children who had moved actively to find the puzzle pieces in the training trials had (a) a greater percentage correct, (b) more correct visits between errors, and (c) a later visit of first error than children who had been passively pushed in a wheelchair. Making active choices in training did not significantly affect performance. A second experiment used identical procedures but tested 32 children with mobility difficulties who regularly used a wheelchair because of either cerebral palsy or spina bifida. Children from this group who moved actively during training to retrieve the puzzle pieces also performed better on testing. Implications of the results for children with disabilities and for developmental theory are discussed.

To evaluate the effectiveness of a fetal monitoring education program in increasing nurses' knowledge and clinical skills.Multicenter randomized control trial.Twelve hospitals in eastern Ontario, Canada.One hundred nine volunteer registered nurses randomly assigned, within each hospital, to an experimental (n = 47) or control (n = 62) group. Ninety-six nurses (40 in the experimental group and 56 in the control group) completed the 6-month follow-up (88% retention).The experimental group participated in a 1-day fetal monitoring workshop and a review session 6 months later.Performance on a 45-item knowledge test and a 25-item skills checklist. The passing score was at least 75% correct on each test.The percentage of nurses in the experimental group passing both the knowledge and the clinical skills tests after the workshop was significantly higher (p0.01) than that of the nurses in the control group: 68.1% versus 6.5%, respectively. A large difference between the groups remained at the 6-month follow-up (experimental, 45%; control, 6.5%). The performance of the nurses in the experimental group improved to an 85% pass rate after they attended the 6-month review session.This comprehensive, research-based program is effective in increasing fetal monitoring knowledge and clinical skills.

The Functional Performance Measure (FPM) is an instrument developed from grounded theory, and measures daily function in persons with Alzheimer Disease. This paper presents a study testing the reliability and validity of the FPM. The study design is based upon generalizability theory that allows the examination of several “facets” to the total variance of the FPM. Twenty-two clients with Alzheimer disease were videotaped performing three activities of daily living. Twelve raters evaluated the clients' performance using the FPM giving 792 completed measures. The FPM demonstrates high inter-rater reliability, moderate reliability across tasks, and criterion and construct validity. The FPM is a measure that will help occupational therapists identify clients' abilities and deficits so that therapists can determine intervention strategies to improve or maintain clients' functional performance.

Background and Purpose. The objectives of this study were (1) to describe the extent to which practicing physical therapists and physical therapy students have reported experiencing inappropriate patient sexual behavior (IPSB), (2) to document the consequences of IPSB, and (3) to identify the strategies the subjects have used to manage IPSB. Subjects and Methods. A survey questionnaire was sent to 118 physical therapists and 87 physical therapy students. Completed questionnaires were returned by 74.1% of the subjects (over 70% in each group). Results. The majority of respondents (80.9%) reported having encountered some level of IPSB. Although almost half of the physical therapists and one third of the third- and fourth-year students reported experiencing severe IPSB, including forceful sexual touching and deliberate sexual exposure, only 20% of the respondents perceived that they had been “sexually harassed.” Most of the respondents were satisfied with the way in which they handled the IPSB; however, almost 90% considered that in-service and undergraduate education would be desirable. Conclusion and Discussion. It is concluded that this problem should be addressed by further study with a broader sample and by inclusion of these issues in education programs for students and physical therapists.

Study objectives: The objectives of this study were to determine whether triage nurses using the Brand protocol would order fewer radiographs than would physicians carrying out standard practice procedures, without missing an increased number of joint or bone injuries; the test characteristics and the interobserver reliability of the Brand protocol; and whether having triage nurses order radiographs could reduce total patient waiting time in the emergency department. Design: Randomized, controlled trial. Setting: The ED of a free-standing children's hospital with approximately 55,000 visits annually. Type of participants: Children less than 18 years of age who had a history of extremity trauma in the preceding seven days. Inteventions: Triage nurses applied the Brand protocol to determine the need for a radiograph. Measurements and results: Of the Brand protocol group, 81.9% had radiographs ordered compared with 87.1% of the control group ( P = .03). The percent of positive radiographs was 40.8% in the Brand protocol group compared with 42.6% in the control group ( P = .21). There were 3.2% (16) missed radiographic findings in the Brand protocol group compared with none in the control group ( P P Conclusion: Having triage nurses use the Brand protocol reduced the number of radiographs ordered but at the same time increased the number of missed radiographic findings. However, having triage nurses order radiographs also significantly shortened waiting time in the ED.

The study objective was to evaluate the reliability, validity, and reactivity of measures eliciting health risk attitudes toward smoking during pregnancy (HRAS). The authors' rationale for studying HRAS, including health expectations, values, and tradeoffs, evolved from interviews with pregnant smokers who stated that health was a primary consideration in the decision to quit smoking during pregnancy. The authors be

We hypothesized that the triage nurse in a busy pediatric emergency department (ED) could accurately order radiographs, ultimately reducing patient waiting time. Protocols utilized to reduce patient waiting time are of importance in busy emergency departments. All patients registering at the ED of the Children's Hospital in a one-week period were entered into the study. The triage nurse documented whether they would send the patient for a radiograph, if allowed to, and were asked to designate a specific radiograph. The radiographs that were actually ordered by the physicians were subsequently obtained from radiology records. Data were analyzed for agreement beyond chance (kappa), positive (PPV) and negative predictive values. The results showed excellent agreement for extremity radiographs and poor agreement for nonextremity radiographs.

To compare dementia risks of elderly black and white subjects and to determine whether differences in education and cognitive test scores contribute to the inconsistency in reported differences between these groups.Longitudinal, 6-year follow-up.Two thousand seven hundred eighty-six older black and white subjects in the Cardiovascular Health Study.Age, education (10 years vsor =10 years), Modified Mini-Mental State Examination score (3MS,or =85 vs85). Potential confounders were sex, depression, apolipoprotein E4 genotype, vascular disease, and baseline magnetic resonance imaging changes.White subjects with low education and black subjects with high education had twice the risk of dementia of white subjects with high education (95% confidence interval (CI)=1.5-2.4 and 95% CI=1.4-2.7); black subjects with low education had five times the risk of dementia (95% CI=3.4-7.7). Likewise, for subjects with low 3MSE scores, black subjects had 6.7 times the risk of dementia (95% CI=4.7-9.7) and white subjects had 2.7 times the risk of dementia (95% CI=2.2-3.5) as white subjects with high 3MSE scores. Finally, in Cox models, there was no significant black-white difference in dementia risk after adjustment for all confounders and baseline 3MSE.Black race was associated with greater dementia risk even after adjustment for education and other potential confounders. This black-white difference in dementia risk was markedly attenuated after adjustment for baseline cognitive screening scores. The apparent race effect may reflect gaps in the quality of education or differences in the trajectory of impaired cognitive function experienced by the two groups. Future investigations might take these findings into consideration for the design of studies evaluating black-white differences in dementia risk.

To estimate the incidence and prevalence of dementia, Alzheimer's disease (AD), and vascular dementia (VaD) in the Cardiovascular Health Study (CHS) cohort.Longitudinal cohort study using prospectively and retrospectively collected data to evaluate dementia.Four U.S. communities.There were 3,602 CHS participants, including 2,865 white and 492 African-American participants free of dementia, who completed a cranial magnetic resonance image between 1992 and 1994 and were followed for an average of 5.4 years.Dementia was classified by neurologist/psychiatrist committee review using neuropsychological tests, neurological examinations, medical records, physician questionnaires, and proxy/informant interviews. Demographics and apolipoprotein E (APOE) genotype were collected at baseline. Incidence by type of dementia was determined using National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for AD and Alzheimer's Disease Diagnostic and Treatment Center's State of California criteria for VaD.Classification resulted in 227 persons with prevalent dementia at entry into the study and 480 incident cases during follow-up. Incidence rates of dementia scaled to age 80 were 34.7 per 1,000 person-years for white women, 35.3 for white men, 58.8 for African-American women, and 53.0 for African-American men. Sex differences were not significant within race. Adjusted for age and education, racial differences were only of borderline significance and may have been influenced by ascertainment methodology. Rates differed substantially by educational attainment but were only significant for whites. Those with the APOE epsilon4 allele had an incidence rate at age 80 of 56.4, compared with 29.6 for those without this allele (P.001). In whites, type-specific incidence at age 80 was 19.2 for AD versus 14.6 for VaD. These rates were 34.7 and 27.2 for African Americans. At termination of observation, women had only a slightly higher prevalence of dementia (16.0%) than men (14.7%).Sex and racial differences were not found, and VaD was higher than reported in other studies. These data provide new estimates of dementia incidence in a community sample for projection of future burden.

Objective To examine the risk factors for mild cognitive impairment (MCI) in a longitudinal population study—the Cardiovascular Health Study Cognition Study. Design We examined the factors that in the period 1991 through 1994 predicted the development of MCI in all participants of the Cardiovascular Health Study Cognition Study. Further examination was conducted in the Pittsburgh, Pa, cohort (n = 927), where participants with MCI were classified as having either the MCI amnestic-type or the MCI multiple cognitive deficits–type. Setting Multicenter population study. Patients This study includes all participants of the Cardiovascular Health Study Cognition Study (n = 3608) who had a magnetic resonance imaging (MRI) scan of the brain between 1991 and 1994, and detailed neuropsychological, neurological, and medical evaluations to identify the presence of MCI or dementia in the period 1998 to 1999. The mean time between the closest clinical examination to the MRI and the diagnostic evaluation for cognitive disorders was 5.8 years for the Cardiovascular Health Study Cognition Study cohort and 6.0 years for the Pittsburgh cohort. Main Outcome Measures Risk factors for MCI at the time of the MRI were identified using logistic regression, controlling for age, race, educational level, baseline Modified Mini-Mental State Examination and Digit Symbol Test scores, measurements of depression, MRI findings (atrophy, ventricular volume, white matter lesions, and infarcts), the presence of the apolipoprotein E ( APOE ) ϵ4 allele, hypertension, diabetes mellitus, and heart disease. Results Mild cognitive impairment (n = 577) was associated with race (African American), low educational level, low Modified Mini-Mental State Examination and Digit Symbol Test scores, cortical atrophy, MRI-identified infarcts, and measurements of depression. The MCI amnestic-type was associated with MRI-identified infarcts, the presence of the APOE ϵ4 allele, and low Modified Mini-Mental State Examination scores. The MCI multiple cognitive deficits–type was associated with low Modified Mini-Mental State Examination and Digit Symbol Test scores. Conclusions The development of MCI is associated with measurements of cognition and depression, racial and constitutional factors, and cerebrovascular disease. Early cognitive deficits seem to be a common denominator for the 2 forms of MCI; the presence of cerebrovascular disease and the APOE ϵ4 allele is associated with the amnestic type of MCI.

Objective To examine the prevalence of mild cognitive impairment (MCI) and its diagnostic classification in the Cardiovascular Health Study (CHS) Cognition Study. Design The CHS Cognition Study is an ancillary study of the CHS that was conducted to determine the presence of MCI and dementia in the CHS cohort. Setting Multicenter population study. Patients We examined 3608 participants in the CHS who had undergone detailed neurological, neuropsychological, neuroradiological, and psychiatric testing to identify dementia and MCI. Main Outcome Measures The prevalence of MCI was determined for the whole cohort, and specific subtypes of MCI were examined in detail only at the Pittsburgh, Pa, center (n = 927). Mild cognitive impairment was classified as either MCI amnestic-type or MCI multiple cognitive deficits–type. Results The overall prevalence of MCI was 19% (465 of 2470 participants); prevalence increased with age from 19% in participants younger than 75 years to 29% in those older than 85 years. The overall prevalence of MCI at the Pittsburgh center was 22% (130 of 599 participants); prevalence of the MCI amnesic-type was 6% and of the MCI multiple cognitive deficits–type was 16%. Conclusions Twenty-two percent of the participants aged 75 years or older had MCI. Mild cognitive impairment is a heterogenous syndrome, where the MCI amnestic-type is less frequent than the MCI multiple cognitive deficits–type. Most of the participants with MCI had comorbid conditions that may affect their cognitive functions.

Background and Purpose— MRI-defined infarcts are common in the elderly. We sought to explore incidence, manifestations, and predictors of such infarcts. Methods— The Cardiovascular Health Study (CHS) is a population-based, longitudinal study of 5888 people aged ≥65 years. Participants have had extensive baseline and follow-up evaluations; 1433 participants underwent 2 MRI scans separated by 5 years and had no infarcts on initial MRI. Results— On follow-up MRI, 254 participants (17.7%) had 1 or more infarcts. Most were single (75.6%), subcortical (79.9%), and small (3 to 20 mm in 87.0%). Only 11.4% of those with infarcts experienced a documented transient ischemic attack or stroke between the scans. Although participants were similar at initial MRI, those with MRI-defined infarcts on follow-up experienced greater decline than those without infarcts on the Modified Mini-Mental State Examination and Digit-Symbol Substitution test (both P Conclusions— Incident MRI-defined infarcts commonly affect the elderly. Most are small, subcortical, and not associated with acute symptoms recognized as a transient ischemic attack or stroke. Nonetheless, they cannot be considered silent because of their association with subtle cognitive deficits. These covert infarcts are associated with white matter changes, which may share a common pathophysiology. Whether control of vascular risk factors, such as blood pressure, would reduce the risk of developing these infarcts and associated cognitive decline deserves further investigation.

PURPOSE. To investigate factors associated with nursing diagnosis utilization. METHODS.A retrospective chart audit was conducted on four hospital units over a 5-month period and linked to the nurses (N =65) who participated in a survey on attitudes toward nursing diagnosis. FINDINGS.Computer-generated nursing care plans resulted in the greatest frequency of nursing diagnosis documentation. Nurses who did not document nursing diagnoses, and nurses employed in hospitals without nursing diagnosis implementation programs, had more positive attitudes toward the value of nursing diagnosis in practice compared with nurses who documented nursing diagnoses and nurses employed in hospitals with implementation programs. CONCLUSIONS.Nurses have a greater tendency to document nursing diagnoses when institutions have formal educational programs and computer-generated care plans.

Advisory committees recommend hepatitis B (HBV) immunization for professional and student health-care workers. However, the currently licensed vaccines are expensive, and previous surveys have shown that few students (14%) have been immunized in Canada. A low-cost immunization program was offered to health-care students in order to determine whether the effectiveness of HBV immunization could be improved by substantially reducing the vaccine cost to recipients. The immunogenicity, side effects, and 3-dose completion rate of a low-cost Korean HBV vaccine were compared with a similar U.S.-made vaccine. A total of 922 postsecondary students enrolled in 6 health-care disciplines in Ottawa, Canada were surveyed for hepatitis-6 immunization status. Nonimmunized students were subsequently offered HBV vaccine at total cost of $15 (Canadian), randomly allocated t o receive 3 intramuscular doses of either Korean or U.S.-made plasma-derived HBV vaccine in a double-blind fashion, surveyed about side effects, and tested for hepatitis B surface antibody seroconversion. Only 12% of the 922 surveyed students had been previously immunized when vaccine was obtainable only at high cost. However, 66% of those not immunized participated in the vaccine trial and paid the $15 fee. Hepatitis-B surface antibody seroconversion (≥10 sample ratio units by radioimmunoassay) occurred in 291/311 (93.6%) and 299/310 (96.5%) of recipients of 3 doses of the Korean and U.S. vaccines, respectively (P = 0.10). There were no meaningful differences in vaccine adverse effects, and 92.6% of recipients of either vaccine completed 3 doses. These results support the view that HBV immunization would be more effective (vaccine acceptance rates higher, greater proportions of persons protected) if lower cost vaccines were marketed. © 1992 Wiley-Liss, Inc.

To determine if the severity of osteoporosis and its resultant hyperkyphosis cause measurable impairment of lung function, 74 women referred for osteoporosis evaluation underwent pulmonary function testing. Women with thoracic wedge compression fractures secondary to osteoporosis had significantly lower percent predicted FVC than did those without fractures. In hierarchical regression analysis, after controlling for age and arm span, there was a significant effect on FVC of the degree of hyperkyphosis as measured by Cobb's angle (increment in R2 = 0.14, p less than 0.001). The addition of the number of vertebral fractures to the model was also significant (increment in R2 = 0.06, p less than 0.002), but cortical bone volume, bone mineral density, and smoking status did not significantly improve the model. From one half of subjects tested, a regression equation was generated relating %FVC and the number of thoracic fractures: %FVC = 103.4 - 9.4 x number of fractures. When used to predict lung function impairment in the second half of study subjects, the correlation between measured and %FVC was r = 0.59 (p less than 0.002). Kyphosis and thoracic compression fractures caused by osteoporosis produce modest but predictable declines in vital capacity in women.

P136 Objective: Silent infarcts seen on cranial MRI scans are a risk factor for subsequent clinical stroke in the elderly. This study examines the type of clinical strokes seen in those with silent infarcts. Methods: Cranial MRI examination was completed on 3324 Cardiovascular Health Study (CHS) participants aged 65+ who were without a prior history of clinical stroke. Incident strokes were identified over an average follow-up of 4 years and classified as hemorrhagic or ischemic. Ischemic strokes were further subdivided into lacunar, cardioembolic, atherosclerotic or other/unknown. Results: Silent MRI infarcts >3mm were found in approximately 28% (n=923). Of these, 7% (n=67) subsequently had a clinically evident stroke. The characteristics of the silent MRI infarcts in those who sustained an incident stroke were as folows: 56 had only subcortical infarcts, of which 55 were Conclusion: Elderly individuals with silent subcortical infarcts who go onto subsequent stroke may be at risk not only for lacunar infarcts but also cardioembolic or hemorrhagic strokes.

"Growing pains" is a benign clinical entity of unknown etiology. This study examines a muscle stretching treatment based on a theory that the etiology of these pains is related to fatigue. The experimental group (18 children) showed a more rapid resolution of their symptoms over an 18 month period when compared to the control group (16 children).

Objective: To determine if individuals ultimately diagnosed with Alzheimer disease (AD) exhibited evidence of cognitive impairment on neuropsychological tests administered between 1.5 years and 8.1 years before dementia onset.Methods: A total of 693 community-dwelling individuals, part of the Cardiovascular Health Study, completed a neuropsychological test battery in 1991/92. Subjects were followed annually over the next 8 years (median follow-up = 7.4 years). Seventy-two individuals were ultimately diagnosed with AD (median follow-up = 4.5 years): 24 with AD onset 1.5 to 3.4 years after baseline neuropsychological testing, 20 with AD onset 3.5 to 5.0 years after testing, and 28 with onset 5.1 to 8.1 years after testing. A total of 621 individuals remained nondemented throughout the 8 years of follow-up (median follow-up = 7.5 years).Results: Subjects ultimately diagnosed with AD had poorer scores on baseline neuropsychological measures than subjects who remained nondemented. Although individuals closest to AD onset (i.e., 1.5 to 3.4 years) performed the most poorly, cognitive impairment was detected in individuals who did not develop AD until 5 to 8 years later.Conclusions: Cognitive changes can be detected well before onset of Alzheimer disease.