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In China, police control of street protests can be accomplished under existing law both directly, through administrative penalties including detention that police can impose on their own authority, and indirectly, through the threat of detention as part of the ordinary criminal process. In the ordinary criminal process Chinese law provides police and prosecutors extensive discretionary authority to detain suspects and defendants for periods of six months or more without judicial review. While the structure of these detention provisions superficially resembles that in Western countries, their operation is wholly subject to internal policies and practices of police and prosecutors. In addition to providing an overview of these provisions, we review here a recent prosecutorial policy change in decision-making on extended detention (dàibǔ, 逮捕) that places the same prosecutor in charge of both this decision and the ultimate presentation of the case. We conclude that this may encourage individual prosecutors to assess their cases more thoroughly and realistically at an earlier stage and may alter the litigation dynamics of detention during the investigative phase, but it does not reduce the threat of detention as a means of deterring protests. At most, the change may provide negotiation opportunities for defence counsel. Until a Chinese criminal case is formally presented to a court, control over detainees remains firmly in the hands of the police and prosecutors.

Individuals who engage in non-suicidal self-injury (NSSI) are heterogeneous across several key features, including functions served by NSSI, frequency of NSSI behaviors, medical severity of injuries, pain experienced during self-injury, and the type and number of methods employed to self-injure. The present study utilized latent class analysis (LCA) to identify distinct subgroups of self-injurers based on a wide array of NSSI features. Participants were 359 undergraduate students with a history of NSSI. Indicator variables of the LCA were the lifetime presence of NSSI methods, number of methods used over one’s lifetime, lifetime and last year frequency rates, presence of NSSI scarring, rating of pain experienced when self-injuring, and functions of NSSI. The analysis yielded four subgroups of self-injurers: a “mild/experimental NSSI” group who endorsed low frequency rates of self-injury and low presence of NSSI functions, a “moderate NSSI” group that endorsed moderate frequency rates of self-injury and moderate presence of NSSI functions, a “moderate multiple functions NSSI” group that endorsed moderate frequency rates of self-injury and high presence of NSSI functions, and a “severe NSSI” group that endorsed high frequency rates of self-injury and high presence of NSSI functions. Following class assignment, groups were found to significantly differ on measures of self-esteem, social support and belongingness, internalizing symptoms, suicidal ideation and behaviors, and other related NSSI constructs. These subtype analyses provide direction for interventions that emphasize matching phenotypes of NSSI to specific interventions based on dimensions of clinical functioning.

The current study investigated whether impaired emotional response inhibition to self-harm stimuli is a risk factor for real-time nonsuicidal self-injury (NSSI) urges. Participants were 60 university students with a history of repetitive NSSI. At baseline, participants completed an emotional stop-signal task assessing response inhibition to self-harm stimuli. Participants subsequently completed an ecological momentary assessment protocol in which they reported negative affect, urgency, and NSSI urge intensity three times daily over a ten-day period. Impaired emotional response inhibition to self-harm stimuli did not evidence a main effect on the strength of momentary NSSI urges. However, emotional response inhibition to self-harm images interacted with momentary negative affect to predict the strength of real-time NSSI urges, after adjusting for emotional response inhibition to neutral images. Our findings suggest that emotional response inhibition deficits specifically to self-harm stimuli may pose vulnerability for increased NSSI urge intensity during real-time, state-level negative affect.

Objective Findings from prior research on reward sensitivity in nonsuicidal self-injury (NSSI) have been mixed. Childhood maltreatment is an independent risk factor for NSSI and for hyposensitivity to rewards. This study aimed to disentangle the role of reward sensitivity as a predictor of NSSI for those with an elevated severity of childhood maltreatment. Method In a diverse undergraduate sample (N = 586), trait reward sensitivity (i.e., behavioral approach system subscales) and the severity of maltreatment were assessed as predictors of a lifetime history of NSSI. In a subset of this sample (n = 51), predictors of NSSI urge intensity were measured using ecological momentary assessment. Results Individuals with elevated maltreatment who reported less positive responsiveness to rewards were more likely to have a lifetime history of NSSI. Those with elevated maltreatment who reported a lower likelihood to approach rewards experienced more intense NSSI urges across the ten-day observation period. However, those with elevated maltreatment who reported a greater likelihood to approach rewards experienced less intense NSSI urges. Conclusions The role of reward sensitivity as a cognitive risk factor for NSSI varies depending on childhood maltreatment history. Findings indicate that, for those with elevated maltreatment, hypersensitivity to approaching rewards may decrease risk for NSSI urges.

Objective The severity of anxiety, in general, has been associated with suicide ideation (SI) among youth, but research has yet to examine the specific anxiety symptoms that may contribute to SI among youth. This study examined the severity of specific anxiety symptom clusters (i.e., tense/restless, somatic/autonomic symptoms, humiliation/rejection, performing in public, separation anxiety, perfectionism, and anxious coping) and SI in youth who met diagnostic criteria for an anxiety disorder. Method Participants (N = 87) were treatment-seeking children and adolescents ages 6-17 (M = 11.1 years, SD = 3.06; 52.9% male) diagnosed with a principal anxiety disorder. Youth and their parents completed measures of youth anxiety symptom severity, depression, and SI. Results Hierarchical linear regressions revealed that when anxiety symptom clusters were entered simultaneously, only youth self-reported (and not parent-reported) somatic/autonomic symptoms of anxiety significantly predicted SI, after controlling for depression and sex. Importantly, the relationship between somatic/autonomic symptoms of anxiety and SI was stronger than that between depression and SI. Conclusions These results suggest that assessing somatic symptoms of anxiety is especially important when quantifying suicide risk among anxiety-disordered youth.

The standard of practice for forensic interviews in criminal and delinquency cases, other than those conducted as part of brief preliminary screening evaluations or in emergency situations, should include a digital recording requirement. This standard should be adopted because of the greater availability of, and familiarity with, recording technology on the part of mental health professionals, the greater use and proven effectiveness of recording in other contexts of the criminal justice system, and the improvement in court presentation and accuracy of judicial determinations involving forensic assessments that recording will provide. The experience of practitioners with recording since professional associations last studied the issue should be taken into account, as informal data suggest it has been positive. Unfortunately, the legal system is unlikely to prompt this advance without its reconsideration by the forensic mental health professions, because current constitutional jurisprudence does not require recording and effectively makes it contingent upon request by examiners. Forensic evaluators thus have a valuable opportunity to educate the legal system on the utility and importance of this key reform, and so should adopt it as a best practice.

The compassionate use of available medications with unproven efficacy is often in conflict with their clinical evaluation in placebo-controlled clinical trials. For ultra-rare diseases where no approved treatments exist, such as fibrodysplasia ossificans progressiva (FOP), routine clinical trial enrollment for available medications may be difficult to achieve. Therefore adaptive methods of evaluation are often desirable. Off-on-off-on (O4) approaches offer an opportunity to rapidly assess the potential symptomatic efficacy and tolerability of a medication with a limited number of patients and may aid in the design of more focused clinical trials that are amenable to enrollment. Here we report three children with classic FOP who had recalcitrant flare-ups of the back and who had been treated with an O4 regimen of imatinib. In all three children, fewer flare-ups, decreased swelling and improved function with activities of daily living were reported by the parents and treating physician when the children were “on” imatinib than when they were “off” imatinib. The median time to improvement on imatinib was 2–3 weeks. The anecdotal O4 experience with imatinib reported here in three children with FOP who had recalcitrant flare-ups of the back supports the design of a brief placebo controlled trial to assess the potential efficacy of imatinib in reducing the symptoms in children with refractory flare-ups of FOP. A tool to prospectively measure and quantitate flare-up symptoms is presently being developed and validated and will be used for such a study.

The Defective Self Model of nonsuicidal self-injury (NSSI) proposes that some people engage in NSSI to punish themselves and/or to respond to self-critical cognitions. Although there is a growing body of research to support this theory, there has been a lack of ecologically valid approaches employed to critically examine its tenets. The current study aimed to fill this gap in the literature. A sample of 64 undergraduates with a history of repetitive NSSI were recruited and completed an ecological momentary assessment (EMA) protocol. At baseline, participants completed trait measures of self-criticism and self-punishment cognitions. Over the EMA period, participants reported their experience of self-critical and self-punitive cognitions, and NSSI urge intensity three times daily. Our between-persons level findings suggest that trait and aggregated state self-punishment, but not self-critical cognitions, predict NSSI urges experienced over the EMA period. Our findings additionally provide evidence that both momentary self-critical and self-punishment cognitions are concomitantly and prospectively associated with NSSI urge intensity as measured in real-time and modeled at a within-persons level. However, after adjusting for concurrent NSSI urge intensity in prospective models, these within-persons level findings do not hold. Nevertheless, our findings provide greater support for the Defective Self Model of NSSI.

BACKGROUND AND OBJECTIVES: Existing models of social anxiety scarcely account for interpersonal stress generation. These models also seldom include interpersonal factors that compound the effects of social anxiety. Given recent findings that two forms of interpersonal distress, perceived burdensomeness and thwarted belongingness, intensify social anxiety and cause interpersonal stress generation, these two constructs may be especially relevant to examining social anxiety and interpersonal stress generation together. DESIGN: The current study extended prior research by examining the role of social anxiety in the occurrence of negative and positive interpersonal events and evaluated whether interpersonal distress moderated these associations. METHODS: Undergraduate students (N = 243; M = 20.46 years; 83% female) completed self-report measures of social anxiety, perceived burdensomeness, and thwarted belongingness, as well as a self-report measure and clinician-rated interview assessing negative and positive interpersonal events that occurred over the past six weeks. RESULTS: Higher levels of social anxiety were associated only with a higher occurrence of negative interpersonal dependent events, after controlling for depressive symptoms. This relationship was stronger among individuals who also reported higher levels of perceived burdensomeness, but not thwarted belongingness. CONCLUSIONS: It may be important to more strongly consider interpersonal stress generation in models of social anxiety.

The US Supreme Court has set 2 key constitutionally based limits to punishment of juveniles; a bar on the imposition of the death penalty for crimes committed by juveniles and of life imprisonment without possibility of parole for juveniles who commit nonhomicide offenses. Both decisions held that these penalties were disproportionate given juveniles' distinctive characteristics. The Court's adoption of a developmental model of culpability may produce future challenges to lengthy juvenile sentences, broad provisions allowing transfer of juveniles for trial as adults, and even possibly to younger juveniles'competence to stand trial.

Pediatric residency practices face the challenge of providing both behavioral health (BH) training for pediatricians and psychosocial care for children. The University of Rochester School of Medicine and Dentistry and Rochester General Hospital developed a joint training program and continuity clinic infrastructure in which pediatric residents and postdoctoral psychology fellows train and practice together. The integrated program provides children access to BH care in a primary care setting and gives trainees the opportunity to integrate collaborative BH care into their regular practice routines. During 1998–2008, 48 pediatric residents and 8 psychology fellows trained in this integrated clinical environment. The program’s accomplishments include longevity, faculty and fiscal stability, sustained support from pediatric leadership and community payers, the development in residents and faculty of greater comfort in addressing BH problems and collaborating with BH specialists, and replication of the model in two other primary care settings. In addition to quantitative program outcomes data, the authors present a case example that illustrates how the integrated program works and achieves its goals. They propose that educating residents and psychology trainees side by side in collaborative BH care is clinically and educationally valuable and potentially applicable to other settings. A companion report published in this issue provides results from a study comparing the perceptions of pediatric residents whose primary care continuity clinic took place in this integrated setting with those of residents from the same pediatric residency who had their continuity clinic training in a nonintegrated setting.

Recent criticism of American legal education has focused on its being theory-driven rather than practice driven, which either produces or reinforces a divide or gap between theory and practice. Yet two of its prominent features expressly draw upon experiential learning, one directly by sending students into experiential learning situations (legal clinics) and the other indirectly by bringing instructors who are engaged full-time in active practice into the classroom (adjunct faculty). This article briefly reviews the ambivalent position of clinics and adjunct faculty in American legal education, to explore the degree to which these approaches to skills development can, or should, be transplanted to other systems of legal education. Drawing on accounts of efforts to develop clinical methods in countries with less adversarial systems, it concludes that legal culture is a critical element in the success, or lack thereof, in transplantation of these approaches.

Psychiatric, psychological, and legal observers have noted persistent shortcomings in the quality of evaluations for competence to stand trial since at least 1965 (Vann, 1965). Recent reviews by Nicholson and Norwood (2000) and Wettstein (2005) of multiple studies (10 and 19, respectively) that assessed the quality of criminal forensic evaluations found "the practice of forensic psychological assessment falls far short of its promise" (Nicholson & Norwood, 2000, p. 40) and that "much work remains to be accomplished in improving the quality of forensic evaluations of evaluators with or without specific forensic training and experience" (Wettstein, 2005, p. 172). Remedies proposed include increased training, specialization, certification, and credentialing of forensic evaluators, although a recent study by Frost, Camara, and Earl (2006) found that as of 2005 only 16 states required or encouraged additional training before evaluators could testify, and only 10 had a forensic certification program. Enlarging the pool of potential forensic evaluators would expand those eligible for specialized training, could reduce shortages of evaluators, and would address conflicts of interest for evaluators employed in the public sector and between evaluators and treaters in the same facility--both noted as ongoing problems (Frost et al., 2006). Social workers, the nation's largest category of licensed clinical mental health professionals, are natural candidates for inclusion in an expanded pool of forensic evaluators--especially to evaluate competence to stand trial. Although forensic evaluation statutes in all but six states now allow psychologists and psychiatrists to be forensic evaluators, only seven states explicitly allow other mental health professionals to conduct forensic evaluations--and then often only of certain evaluations or in certain types of cases (Frost et al., 2006). Despite this moderate statutory and regulatory expansion of professionals eligible to conduct forensic evaluations (Frost et al., 2006), trial courts---even without explicit statutory or regulatory authority--are expanding the pool of those who can give expert testimony on competence issues to include clinical social workers based on judges' inherent power to qualify persons as expert witnesses (State v. Reese, 1989; State v. Gans, 1983; State v. Scala, 1985; People v. R. R., 2005; People v. Villanueva, 1988; State v. Torres, 2001; State v. Mackey, 1982; United States v. McCarthy, 1995). Competence questions, the most frequently arising forensic mental health issue in criminal cases, produce an estimated 50,000 to 60,000 evaluations annually (Bonnie & Grisso, 2000; Rogers, Grandjean, Tillbrook, Vitacco, & Sewell, 2001). Social workers in mental health organizations and general hospital psychiatric services have outnumbered combined psychiatrists and psychologists in these facilities since 1990 (National Mental Health Statistics, 1998). Despite the clinical burden competence evaluations impose, the statutes and administrative regulations of only eight states--Connecticut [Conn. Gen. Star. Ann. [section] 54-56d(d) (2006) (as a clinical team member)]; Louisiana [La. Stat. Ann., Code Crim. Pro. Art. 644; Art. 646 (2006) (as a clinical team member)]; Nevada [Nev. Rev. Stat. [section] 178.415 (2006) (for misdemeanors only)]; North Carolina [N.C. Gen. Stat. Ann. [section] 15A-1002; N.C. Admin. Code tit. 10A, r. 27G.0104 (2006)]; South Carolina [S.C. Code 1976 [section][section] 44-23-410; 44-23-10 (2005); S.C. Admin. Code Sec. 87-1 (2005)];Tennessee [Tenn. Code Ann. [section] 33-7-301;Tenn. Comp. R. & Reg. Ch. 0940-3-3.07 (2005)]; Utah [Utah Code Ann. 1953 [section][section] 77-15-5; 62A-15-602(3), 62A15-606 (2005)]; and Washington [West's Rev. Code Wash. 10.77.060.; 10.77.010 (2005)])--explicitly permit appointment of clinical social workers to conduct competence-to-stand-trial evaluations, whereas all 46 states that specify who can perform evaluations allow appointment of any licensed psychiatrist or (in all but one) any licensed psychologist. …

People’s mental processes, particularly how they see and understand other people, change as they grow, and the criminal law should take this into account. Vastly oversimplified, this is the fundamental premise of The Mind of the Criminal: The Role of Developmental Social Cognition in Criminal Defense Law, Reid Griffith Fontaine’s elegant tour of seven areas of the American criminal justice system’s recognition—or failure to recognize—the new “social-cognitive jurisprudence.” What can psychological research concerning how people develop their understanding of, views about and feelings toward, others, offer the criminal justice system?We all attach meaning, undertake behaviors and have emotions in response to the words and actions of others (social information), and how we do that depends upon our social cognition. Theories of social cognition, most significantly social information processing (SIP) theory, seek to explain why individuals respond differently (sometimes violently) to these social stimuli, which could have great significance for the criminal law. Individual differences in social cognition that could impair a person’s ability to make sense of social information could make such a person act in a way that was less controlled or less rational, which might suggest reduced criminal responsibility. Impaired social cognition, or social cognition that has developed through initial responses and feedback to these, could lead to misinterpreting social information, for example by misperceiving as threats social information that most people would perceive as nonthreatening, which could affect the reasonableness of a person’s response. This book collects developmental psychological research (much done by Fontaine himself) into a coherent theory that Fontaine applies to the basic situations in which the criminal law makes allowances for reduced, impaired, insufficiently developed or absent rationality. The particular processes by which persons who engage in antisocial behavior understand their social environment is undeniably an important inquiry for the criminal law, as the views of perpetrators towards other persons might help us Crime Law Soc Change (2012) 58:563–565 DOI 10.1007/s10611-012-9400-3

The continuing duty of criminal defense counsel to their former clients, even when those former clients bring post-conviction actions alleging ineffective assistance of counsel, has existed as a national practice standard in capital cases since at least 1987. In addition to its inclusion in the ABA’s Guidelines for the Appointment and Performance of Counsel in Death Penalty Cases since 1989, duties to former clients exist in all state ethics rules (as well as the ABA Model Rules of Professional Conduct). The duty has been further operationalized in non-capital litigation (as well as capital litigation) through a 2010 ABA formal ethics opinion concerning disclosures by trial counsel to prosecutors in ineffective assistance of counsel (IAC) claims, case law and scholarship. There are no empirical data concerning its operation in practice, and these are difficult to obtain because much of the continuing duty operates through informal practices. This paper describes the results of a brief survey intended to develop these data.

To characterize the differences and similarities among college freshmen, sophomores, juniors, and seniors regarding their sexual behavior including contraception choices and human immunodeficiency virus (HIV) risk.A 41-item sexual behavior questionnaire designed for this study was administered to a convenience sample (N = 797) of a college population.Levels of sexual activity were found to be comparable to other college-based surveys. Notable trends included an increased level of oral contraceptive use among partners reported by seniors, as compared to freshmen, without a corresponding increase in condom use; an increased reliance among seniors, as compared to freshmen, on women to provide contraception; and a low level of self or partner HIV testing either before or after initiating sexual intercourse. Gender differences also revealed greater partner relationship duration, intensity, and communication prior to initiating sexual intercourse among women versus men (por = .001).Sexual behavior among college students differs across the 4 years with regard to rates of intercourse, contraception choice, and responsibility, as well as HIV testing and partner trust. University- and college-based health care programs should address sexual behavior with an awareness of the differences that exist in the four cohorts of students.This study aimed to describe the differences and similarities among college freshmen, sophomores, juniors, and seniors concerning their sexual behavior, including contraception choices and HIV risk. The sample (N = 797; mean age = 19 years) were taken from a private 4-year undergraduate college and represented 17% of the college population. It consisted of 474 (60%) females and 318 (40%) males. They were interviewed through the use of a 41-item questionnaire administered in a cross-sectional survey design. In the results, levels of sexual activity were similar to other college-based surveys with 72% reporting ever having had sexual intercourse. The average age of first sexual intercourse was 16.8 years for females and 16.7 for males; 358 (45%) were currently sexually active. Condoms were the most common contraception used, followed by oral contraceptives. The primary purpose in choosing a contraceptive was prevention of both pregnancy and disease. Seniors had increased level of oral contraceptive use and increased reliance on women to provide contraception as compared to freshmen. The percentage of students who had undergone HIV testing also increased from freshman (16%) to senior (32%) years. As to gender differences, women reported greater partner relationship duration, intensity, and communication prior to initiating sexual intercourse as compared to men. In conclusion, college-based health care programs should address sexual behavior with an awareness of the differences that exist in the 4 cohorts of students.

Purposes: To determine self-reported honesty in completing a sexual and other risk behavior questionnaire among middle and high school students, and to relate honesty scores to sexual behavior item responses as a method to detect bias in reporting. Methods: A self-administered questionnaire measuring overall honesty (7-point rating scale), sexual honesty (5-category scale), and selected sex behaviors was used. Urban, predominantly minority middle and high schools (Grades 7–12) were examined, and participants were 3144 male and female students in middle (mean age=13.7 ± 2.0) and high (17.3 ± 1.6) school health classes. Results: The majority of students stated that they had been very or completely honest in responding to items on the questionnaire. Seventy-eight percent of middle school males (lowest rate), and 94% of high school females (highest rate) reported honesty. Middle school males were most likely to declare dishonesty regarding sexual behavior items, overstating their actual behavior (14%), while middle school girls were most likely to understate (8%) their behavior. Self-reported sexual honesty and reports of behavior were most consistent for understaters. That is, those subjects who answered that their questionnaire responses underreported their true sexual behavior did, in fact, report lower sexual activity on selected survey items. Conclusion:> Middle and late adolescents reported high levels of honesty in responding to a sexuality-related questionnaire. When interpreting such questionnaire data, correction for the tendency to overstate among middle school males and understate among middle school females should be considered; conclusions about self-reports of sexual behavior among young adolescents need to take into account degree of honesty. However, the presence of some overreported and some underreported behavior does not invalidate interpretation of the overall survey findings.

One hundred seventy-eight graduates from four primary care residency training programs with common hospital sites (medicine/pediatrics, 72; family medicine, 29; pediatrics, 35; and internal medicine, 42) responded to a mailed survey questionnaire regarding distribution of professional time and self-perceived clinical competencies. Most of the internists, family physicians, and internist/pediatricians (MED/PED) were in primary care, and 57% of the pediatricians were subspecialists. Respondents rated each of 24 clinical vignettes as to their level of comfort in managing the patient problems presented. MED/PED and pediatricians responded similarly to all the infant, child, and adolescent cases. Family physicians were less comfortable in managing the complicated neonatal situations but more comfortable with adolescent health care than the MED/PED or pediatricians. MED/ PED reported greater comfort than family physicians in complex internal medicine issues, but less than internists in intensive care and geriatric consultation. Significant differences in reported competency existed among these primary care practitioners despite substantially overlapping training backgrounds.

Clearly, a multitude of potential consent problems can exist for the emergency physician. It is difficult at times to balance the concepts of patient autonomy with the desire to provide optimal medical care. Experienced emergency physicians should be able to individualize the type of consent needed in a particular situation, based on a clinical evaluation of the case. Some general principles apply, but no strict rules can guide the physician in every case. Documentation of consent and refusal of treatment are critical for quality of patient care and legal liability reasons. Principles of what is good, "appropriate" legal consent usually follow from good medical care and strict concern for the patient's health and rights.

Purpose To determine whether former pediatric residents trained using a model of integrated behavioral health (BH) care in their primary care continuity clinics felt more comfortable managing BH care and better prepared to collaborate with BH professionals than did peers from the same residency who trained in clinics with a conventional model of BH care. Method University of Rochester School of Medicine and Dentistry pediatric residents were assigned to one of two continuity clinic sites. At one site, psychology fellows and faculty were integrated into the clinic teams in the mid-1990s. At the other, conventional patterns of consultation and referral continued. In 2004, the authors surveyed 245 alumni (graduated 1989-2003) about their experiences and their comfort with providing BH care and collaborating with BH providers in their current practice. Results A total of 174 alumni (71%) responded. There were significant differences between graduates who trained in the two models. Those who trained in the integrated model were significantly more likely than others to report that they had consulted or planned treatment with a BH provider during residency and to report that their continuity clinic helped prepare them to collaborate with BH providers. They were somewhat more likely to believe that their overall residency training prepared them to manage BH issues in their current practice. Conclusions These findings suggest that an integrated training environment, described in detail in the companion article in this issue, can enhance pediatric resident education in the management of BH problems and collaboration with BH specialists.

Cadmium and cadmium compounds are carcinogenic both by inhalation and by injection. For purposes of risk assessment, a prudent public health approach has been that, if a chemical has been demonstrated to be carcinogenic by one route, it should be considered carcinogenic by all routes. This policy has been questioned for several toxic metals including cadmium. After reviewing the literature on cadmium carcinogenicity and genotoxicity, we think that cadmium should be considered noncarcinogenic by the oral route. The bases for this decision included: (1) a database for genotoxicity of cadmium with more negative test results than positive results and with most positive results in in vitro tests, indicating that cadmium has limited genotoxicity; (2) some epidemiologic evidence of respiratory tract cancer and prostatic cancer in people occupationally exposed to airborne cadmium but no reliable evidence of gastrointestinal tract cancers in workers; and (3) a large dietary oncogenicity study in rats of cadmium chloride at several dose levels, including a maximally tolerated dose (50 ppm) in males, which showed no increase of tumors due to cadmium ingestion in all of the 19 tissues examined. The conclusion that an agent, which has been shown to be carcinogenic by one route of exposure, is not carcinogenic by a second route should be made only in the presence of robust data which indicate the lack of effect via the second route of exposure.

Lead exposure is an insidious problem, causing subtle effects in children at low exposure levels where clinical signs are not apparent. Although a target blood lead concentration (Pb(B)) of ten micrograms per deciliter (10 microg/dL) has been used as the basis for environmental decision-making in California for nearly two decades, recent epidemiologic evidence suggests a relationship between cognitive deficits and Pb(B) at concentrations10 microg/dL. Based on a published meta-analysis of children's IQ scores and their blood lead concentrations, we developed a new blood lead benchmark: an incremental increase in blood lead concentration (DeltaPb(B)) of 1 microg/dL, an increase that we estimate could decrease the IQ score in an average school child in California by up to one point. Although there is no evidence to date for a threshold for the neurobehavioral effects of lead, a one-point IQ decrement was chosen to represent a de minimus change. To safeguard the intellectual potential of all children, additional efforts to reduce or eliminate multiple-source exposures to lead are warranted.

Munchausen Syndrome by Proxy (MSP) is a disturbing diagnosis that should be considered when persistent signs and symptoms defy adequate explanation despite extensive testing. Insistence by a parent (often mother) that more, and particularly invasive investigations be pursued, should serve as a warning sign that MSP might be present. The primary care provider who has an existing, over-time, relationship with the child and family is in an important position to raise the question of MSP because this professional may be able to recognize larger dynamics at play between child and family that are less apparent to subspecialists who are focused on a narrow aspect of the evaluation. A confounding element to identifying MSP can also be at play when parent(s) have become proficient in the jargon and technical communication with which professionals on the healthcare team are most comfortable. This easily occurs in cases of MSP both because frequent hospitalizations offer ample opportunity for the articulate and inquisitive parent to pick up the ways of "medical-speak," and because the World Wide Web provides countless and effortlessly accessible sources of disease related information (albeit not always accurate or relevant to the diagnostic dilemma in question). An additional complicating factor in posing a risk for MSP is the child with a chronic illness, or one whose neonatal course has served to label the child as vulnerable.

Musculoskeletal complaints, and joint pain in particular, are common symptoms among adolescents presenting to primary care providers. In this article, the distinction between arthralgia and arthritis is described, and important inflammatory arthropathies seen in teenagers are addressed. The current nomenclature of juvenile idiopathic arthritis is used to address each of the major clinical entities that account for chronic arthritis in teens, including oligoarthritis, polyarthritis, systemic arthritis, psoriatic arthritis, and spondyloarthropathy. Diagnostic criteria, important comorbidities, and principles of management are summarized with identification of antiinflammatory, immunosuppressive, and cytokine-specific biological agents and their relative uses. Other categories of chronic arthritis are also discussed, including infection-associated reactive arthritis, Lyme disease, joint disease of inflammatory bowel disease, as well as chronic arthritis as a dimension of other autoimmune diseases. In addition to the biomedical dimension of these disorders, the psychological impact and developmental context of persistent pain and musculoskeletal abnormality in adolescents are commented on.

Objective Macrophage activation syndrome is characterized by an overwhelming inflammatory reaction driven by excessive expansion of T cells and hemophagocytic macrophages. Levels of soluble interleukin-2 receptor alpha (sIL-2Ralpha) and soluble CD163 (sCD163) may reflect the degree of activation and expansion of T cells and macrophages, respectively. This study was undertaken to assess the value of serum sIL-2Ralpha and sCD163 in diagnosing acute macrophage activation syndrome complicating systemic juvenile idiopathic arthritis (JIA). Methods Enzyme-linked immunosorbent assay was used to assess sIL-2Ralpha and sCD163 levels in sera from 7 patients with acute macrophage activation syndrome complicating systemic JIA and 16 patients with untreated new-onset systemic JIA. The results were correlated with clinical features of established macrophage activation syndrome, including ferritin levels. Results The median level of sIL-2Ralpha in the patients with macrophage activation syndrome was 19,646 pg/ml (interquartile range [IQR] 18,128), compared with 3,787 pg/ml (IQR 3,762) in patients with systemic JIA (P = 0.003). Similarly, the median level of sCD163 in patients with macrophage activation syndrome was 23,000 ng/ml (IQR 14,191), compared with 5,480 ng/ml (IQR 2,635) in patients with systemic JIA (P = 0.017). In 5 of 16 patients with systemic JIA, serum levels of sIL-2Ralpha or sCD163 were comparable with those in patients with acute macrophage activation syndrome. These patients had high inflammatory activity associated with a trend toward lower hemoglobin levels (P = 0.11), lower platelet counts, and significantly higher ferritin levels (P = 0.02). Two of these 5 patients developed overt macrophage activation syndrome several months later. Conclusion Levels of sIL-2Ralpha and sCD163 are promising diagnostic markers for macrophage activation syndrome. They may also help identify patients with subclinical macrophage activation syndrome.

This paper presents the computational architecture for the Utah-MIT hand, and discusses design issues encountered in its hardware and software development. The large number of linkages, actuators, and sensors offers a potentially severe computational burden for control; a multiprocessor hardware configuration has been developed to distribute this computation. In the interests of efficiency, minimal operating systems were devised for each processor which nevertheless were made sufficiently general for task scheduling, intertask communication, and debugging. This computational architecture is a general system which is potentially useful for other robotics applications.