Search

Introduction and purpose We evaluated the impact of developmentally-at-risk status on the results of photorefractive screening with iScreen®. Patients and methods We sequentially recruited 169 children (aged 2-5 years) to participate in a blinded, prospective study of a photoscreening device. The principle investigator examined the children after photoscreening. Using established standards for amblyogenic factors, the principle investigator and photoscreen interpreters separately made a determination of "normal" or "needs referral" for each child. Sensitivity, specificity, positive predictive value, and negative predictive value for the photoscreening device were determined. Results Overall, sensitivity was 85% with a positive predictive value of 98%, and specificity was 87% with a negative predictive value of 47%. Developmentally-at-risk status in 34 children (three refused imaging) did not reduce sensitivity (89%) or specificity (100%) when compared with 130 children (two refused imaging) who did not have developmentally-at-risk factors (sensitivity = 84% and specificity = 80%). Conclusion The efficacy of photorefractive screening in young children with developmentally-at-risk status is comparable to results found in normal children.

Objective—This study examined the role of demographic characteristics, psychological factors, and family functioning on attendance in a randomized controlled trial of a family-based pediatric obesity program. Method—Participants included 155 children between the ages of 4 and 7 years (M age = 5.77, 57.4% female, 73.6% African-American, M BMI = 25.5) and their primary caregivers who were randomized to the treatment group. Three groups of participants were created based on their patterns of attendance during the program: 1) noncompleters, 2) partial completers, and 3) completers. Results—Results indicated no differences among the attendance groups in child gender, child BMI, or child psychological functioning. Significant group differences were found with respect to race/ethnicity, parent marital status, and family income, such that noncompleters were more likely to be racial/ethnic minorities, to living in single parent households, and to have lower incomes than partial completers and completers. After controlling for the effects these socio-demographic risk factors, noncompleters and partial completers reported more family dysfunction characterized by high levels of disengagement than completers. Conclusion—Adapting existing weight management programs to include a focus on family engagement in the early stages of treatment may help to improve participation in family-based obesity interventions targeting high risk, socio-economically disadvantaged youth.

WE REPORT A prospective, randomized, blinded clinical trial comparing seizure and neuropsychological outcomes from anterior temporal lobectomies between two groups of patients. One group (n = 34) underwent hippocampal resection posteriorly to the anterior edge of the cerebral peduncle (partial hippocampectomy). In the other group (n = 36), the hippocampus was removed further to the level of the superior colliculus (total hippocampectomy). The amount of lateral cortical resection was the same between groups. Patients were and neuropsychological morbidity. At 1 year postoperatively, the total hippocampectomy group had a statistically superior seizure outcome compared with the partial hippocampectomy group (69 versus 38% seizure-free), and examination of time to first seizure (survival analysis) revealed significantly superior outcomes associated with total hippocampectomy. There was no increased neuropsychological morbidity associated with the more extensive hippocampal resection.

Cluster analysis was used in the attempt to derive a meaningful taxonomy of academic competence in 117 adults with temporal lobe epilepsy. Reading, spelling and arithmetic achievement scores from the Wide Range Achievement Test-Revised were subjected to hierarchical complete linkage cluster analysis, and the stability of the obtained solution was examined by the application of two additional clustering procedures. A six cluster solution was obtained, and tests of internal validity showed membership in four of the clusters to be extremely stable (Moderate and Marked Reading/Spelling Underachievement, Above Average Achievement, Reading/Arithmetic Underachievement), while the remaining two clusters showed some exchange of cases (Arithmetic Underachievement, Average Achievement). Modest evidence of external validity was found through the comparison of specific clusters to the Average Achievement group on measures of neuropsychological function, neurological and demographic characteristics. It is concluded that cluster analysis may be helpful in developing taxonomies of psychosocial impairment in epilepsy, and may facilitate an understanding of the determinants of variable quality of life outcomes associated with epilepsy.

The integrity of language function after a left (dominant) anterior temporal lobectomy performed without the use of functional mapping remains controversial. Much of the controversy concerns the degree to which analyses of group data obscure the identification of surgically induced dysnomia in individual patients. This study investigated postoperative language outcome in our entire series (n = 162) of nonretarded, left hemisphere speech dominant patients with intractable nonlesional epilepsy who underwent a left (n = 85) or right (n = 77) anterior temporal lobectomy without functional mapping. A comparison of preoperative to (6 mo) postoperative performance on a standardized test of nominal speech revealed the following: 1) a statistically significant but clinically modest difference in outcome between left and right anterior temporal lobectomy groups; 2) a subgroup (7%) of left anterior temporal lobectomy patients exhibited a postoperative dysnomia (a decline in nominal speech that exceeded the worst performance in the right anterior temporal lobectomy group); and 3) a postoperative decline in nominal speech after left anterior temporal lobectomy was specifically associated with a later age at the onset of epilepsy. Within the context of group data suggesting minimal risk to language function when functional mapping is not used, a small subgroup of individuals characterized by a later onset of epilepsy can be identified who exhibit a surgically induced dysnomia after a standard left anterior temporal lobectomy. Whether these results differ from the outcome of functional mapping remains to be determined.

It is unknown whether keeping a firearm in the home confers protection against crime or, instead, increases the risk of violent crime in the home. To study risk factors for homicide in the home, we identified homicides occurring in the homes of victims in three metropolitan counties.After each homicide, we obtained data from the police or medical examiner and interviewed a proxy for the victim. The proxies' answers were compared with those of control subjects who were matched to the victims according to neighborhood, sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods.During the study period, 1860 homicides occurred in the three counties, 444 of them (23.9 percent) in the home of the victim. After excluding 24 cases for various reasons, we interviewed proxy respondents for 93 percent of the victims. Controls were identified for 99 percent of these, yielding 388 matched pairs. As compared with the controls, the victims more often lived alone or rented their residence. Also, case households more commonly contained an illicit-drug user, a person with prior arrests, or someone who had been hit or hurt in a fight in the home. After controlling for these characteristics, we found that keeping a gun in the home was strongly and independently associated with an increased risk of homicide (adjusted odds ratio, 2.7; 95 percent confidence interval, 1.6 to 4.4). Virtually all of this risk involved homicide by a family member or intimate acquaintance.The use of illicit drugs and a history of physical fights in the home are important risk factors for homicide in the home. Rather than confer protection, guns kept in the home are associated with an increase in the risk of homicide by a family member or intimate acquaintance.

A 35-item Frequency Recall Evaluation of Dietary Intake Instrument (FREDI) was developed, validated, and tested for describing meaningful dietary patterns in adults (n-353) and teenagers (n=531) in Eastern NC. Validity studies showed that the FREDI instrument could predict (p

There is a substantial genetic component to birth weight variation. We tested eighteen single nucleotide polymorphisms (SNPs) in the IGF2, H19, and IGF2R genes for associations with birth weight variation in 342 mother-newborn pairs (birth weight 2.1 – 4.7 Kg at term) and 527 parent-newborn trios (birth weight 2.1 – 5.1 Kg) across three localities. SNPs in the IGF2R (rs8191754; maternal genotype), IGF2 (rs3741205; newborn genotype) and in the 5' region of the H19 (rs2067051, rs2251375, and rs4929984) genes were associated with birth weight. Detailed analyses to distinguish direct maternal, direct newborn, and parent of origin effects for the most strongly associated H19 SNP (rs4929984) determined that the association of maternal genotype with newborn birth weight was due to parent of origin effects, not direct maternal effects. That SNP is located near the CTCF binding sites that influence expression of the maternally-imprinted IGF2 and paternally-imprinted H19 locus, and there are statistically significant and independent opposite effects of the same rs4929984 allele, depending on the parent from which it was inherited.

This investigation tested the hypothesis that the degree of impairment to memory function caused by an anterior temporal lobectomy (ATL) is inversely related to the pathological status of the resected hippocampus. Specifically, the greatest risk to postoperative memory function should be to patients with no or minimal hippocampal sclerosis, i.e., those with a functional hippocampus. Forty patients who underwent a partial resection of the left (n = 21) or right (n = 19) anterior temporal lobe were administered tests of immediate and delayed verbal and figural memory, both preoperatively and 6 months postoperatively. The degree of postoperative impairment in memory function was then investigated as a function of the degree of hippocampal sclerosis, as determined by a standardized procedure. For a left ATL, an absence or mild degree of hippocampal sclerosis was associated with significantly greater postoperative impairment of both verbal and figural memory, compared with patients with moderate or marked sclerosis. No statistically significant relationship was noted for patients who underwent a right ATL, but the findings were in the same direction for five of six memory measures. It may be possible to predict and avoid surgically induced impairment of memory function among patients who undergo left ATL through the use of preoperative hippocampal volumetric magnetic resonance imaging. Better clinical tests of right hippocampal function are needed to predict the outcome for patients who undergo a right ATL.

We hypothesize that neuropeptides are involved in temporal lobe epilepsy. To elucidate the molecular mechanisms involved in epilepsy, several opioid neuropeptides were measured in surgically removed human temporal lobe cortex. The opioid neuropeptides studied derived from several different precursor molecules, including proenkephalin A, which produces methionine enkephalin (ME=TyrGlyGlyPheMet=YGGFM), leucine enkephalin (LE=TyrGlyGlyPheLeu=YGGFL), and ME-RGL (TyrGlyGlyPheMetArgGlyLeu), and proopiomelanocortin (POMC), which produces β-endorphin (BE). Opioid neuropeptide receptor activity was measured in tissue obtained from the medial (epileptogenic focus) temporal cortex (MTC) and the lateral (nonfocus) temporal cortex (LTC). The epileptogenic focus was localized previous to surgery by long-term ictal monitoring with surgically implanted subdural strip electrodes. The opioid neuropeptide receptor activity content in the MTC and LTC tissue samples was compared between patients who were seizure-free (or had auras only) and those who were not seizure-free postoperatively. The methionine enkephalin-like receptor activity (ME-lr) measurements were the only values that showed significant difference. The amount of ME-lr in the MTC of patients who remained seizure-free (or had auras only) after surgery was significantly higher ( p = 0.013) (2.53 pmol ME-lr mg −1 protein; n=26; median) versus those patients who continued to have postsurgical seizures (or had no change) (0.64 pmol ME-lr mg −1 protein, n=14; median).

Treatment studies provide minimal support for nicotine replacement therapy (NRT) with youth; however, survey studies suggest that adolescents use NRT, and may engage in inappropriate use. The current study sought to examine patterns of NRT use and risk factors for use to further aid smoking cessation efforts including prevention of potential misuse. In-school surveys assessing socio-demographic and behavioral factors associated with NRT use, gum or patch, were completed by 4078, predominantly African American, high school students. Approximately 5% of students reported former or current use of NRT products: 42% gum, 29% patch, and 29% both gum and patch. Among smokers, 5.4% reported use of both NRT gum and patch, with exclusive use of gum twice as likely as exclusive use of the patch. Those with high-risk-taking attitudes were more likely than low-risk takers (3% vs. 1%) to report use of both products, with exclusive gum use more prevalent than patch use. A cumulative logit model revealed males, risk takers, and/or smokers were at greatest odds for NRT use. Among this adolescent sample, NRT gum was used more often than the patch. Adolescent males, risk takers, and/or smokers appear more likely to use NRT (gum and/or patch) compared to their counterparts, despite limited empirical support for effective use of these products as cessation aids among adolescents. Smoking cessation and prevention programs may emphasize appropriate NRT use, specifically within these populations.

Human birth weight variation has a significant genetic component and important clinical consequences. We performed a survey of single nucleotide polymorphisms (SNPs) in 14 candidate genes to identify associations with birth weight variation.SNP variation was surveyed in 221 healthy African-American mother-newborn pairs. Genes were selected based on previous association with obesity-related traits, significant differences in circulating protein levels in low birth weight pregnancies or association with newborn size in model organisms or growth disorders in humans. Association was tested via multiple linear regression with adjustment for significant covariables.Under a dominant model SNP rs7754561 of ENPPI was significantly associated with birth weight. Among imprinted loci, maternal genotypes for SNP rs6026576 of GNAS were significantly associated with birth weight (additive and dominant models). This association was restricted to male offspring. Analyses that distinguished between alleles of paternal and maternal origin demonstrated that only maternally-transmitted alleles were associated with birth weight and that this association was restricted to male newborns.The effect of only maternally-transmitted alleles of GNAS may be a consequence of the complex splicing and imprinting pattern of the GNAS gene, although the reason this effect is observed only among male newborns is unclear.

To determine whether the variable nucleotide tandem repeat polymorphism in intron 2 of the interleukin-1 receptor antagonist gene is associated with lung injury in children with community-acquired pneumonia.A prospective cohort of children diagnosed with community-acquired pneumonia.Two pediatric hospitals.Eight hundred fifty pediatric patients with community-acquired pneumonia were enrolled.Genotyping of the variable nucleotide tandem repeat polymorphism in intron 2 of the interleukin-1 receptor antagonist gene was performed on DNA isolated from whole blood.The requirement for positive pressure ventilation or the diagnosis of acute lung injury or acute respiratory distress syndrome were the main outcomes of the study. Children (14 days-19 yrs) with community-acquired pneumonia (850) were enrolled; analysis was limited to African American (515) and Caucasian (232) patients. Of the 82 patients requiring positive pressure ventilation, 44 were diagnosed with acute lung injury or acute respiratory distress syndrome. Multivariate logistic regression analyses indicated that children without a copy of the A1 allele of the variable nucleotide tandem repeat polymorphism in intron 2 of the interleukin-1 receptor antagonist gene were more likely to need positive pressure ventilation compared to those with one or two copies of this allele (odds ratio = 2.65, confidence interval, 1.02-6.90). In addition, the absence of the A1 allele also appeared to be associated with the development of community-acquired pneumonia-induced acute lung injury/acute respiratory distress syndrome (odds ratio = 3.1, confidence interval, 0.99-9.67).In children with community-acquired pneumonia, absence of the A1 allele at the interleukin-1 receptor antagonist intron 2 polymorphic site is associated with increased risk for more severe lung injury, as measured by the need for positive pressure ventilation or the development of acute lung injury or acute respiratory distress syndrome. Conversely, presence of the A1 allele is associated with decreased risk for more severe lung injury in this patient population.

To test the hypothesis that increased long-term mortality after hospitalization for community-acquired pneumonia (CAP) is independent of comorbid conditions.Prospective observational cohort study in metropolitan areas.Memphis, Tennessee, and Pittsburgh, Pennsylvania.Three thousand seventy-five subjects aged 70 to 79 over 5.2 years.Unadjusted and adjusted mortality from an initial hospitalization for CAP were compared with mortality from different causes of hospitalization, including cancer, fracture, congestive heart failure (CHF), cerebrovascular accident (CVA), and other causes. Demographics, smoking, nutritional markers, functional status, inflammatory markers, and chronic health conditions were adjusted for.Of the 106 subjects hospitalized for CAP, 22 (20.8%) and 38 (35.8%) died at 1 and 5 years. Subjects hospitalized with CAP had higher mortality than nonhospitalized subjects (adjusted odds ratio (OR)=7.8, 95% confidence interval (CI)=4.2-14.4). One- and 5-year mortality after CAP hospitalization were higher than mortality from other causes requiring hospitalization and remained unchanged in multivariable analysis (adjusted OR=3.5, 95% CI=1.5-8.1; adjusted OR=5.6, 95% CI=2.8-11.2, respectively). One- and 5-year mortality after hospitalization for CAP were similar to or higher than mortality after an initial hospitalization for CHF, CVA, or fracture. Rehospitalization was common in subjects hospitalized for CAP and may explain greater long-term mortality.In this high-functioning cohort of older persons, an initial hospitalization for CAP was associated with greater long-term mortality, independent of prehospitalization comorbid conditions. Hospitalization for CAP has as serious a prognosis as hospitalization for CHF, stroke, or major fracture.

Background Assessing whether and how adolescents use nicotine replacement therapy (NRT) will be important given recent recommendations to make NRT more accessible by lowering its price, increasing its distribution, and advising health care professionals to suggest its use for smoking cessation. Objectives To report the prevalence, ease of access, and reasons for NRT use and describe inappropriate use in adolescent smokers and nonsmokers. Design Cross-sectional survey of 4078 high school students during the school term of 1998. Setting City schools in Memphis, Tenn. Main Outcome Measures Community-based self-reported prevalence of NRT use and characteristics of those using NRT. Results Approximately 5% of adolescents reported trying or using nicotine gum or patches. Females were less likely than males and African Americans were less likely than others to use NRT. For African American smokers, NRT use was highest at lower smoking levels, while other smokers showed the opposite pattern. Almost 40% of former smokers reported using NRT to try to quit smoking; however, 75% of current smokers endorsed using NRT for reasons other than trying to quit smoking. Other inappropriate use of NRT was reported; 18% of NRT users reported themselves as never smokers. More than 50% of students reported that it would be easy for them to get NRT. Conclusions Nicotine replacement therapy is used by adolescent smokers and nonsmokers, is easily accessible, and is used for reasons other than trying to quit smoking. Efforts are needed to discourage NRT use in nonsmoking youth and to encourage appropriate use of NRT in young smokers to maximize its potential for successful cessation.

Determine the relative frequency with which guns in the home are used to injure or kill in self-defense, compared with the number of times these weapons are involved in an unintentional injury, suicide attempt, or criminal assault or homicide.We reviewed the police, medical examiner, emergency medical service, emergency department, and hospital records of all fatal and nonfatal shootings in three U.S. cities: Memphis, Tennessee; Seattle, Washington; and Galveston, Texas.During the study interval (12 months in Memphis, 18 months in Seattle, and Galveston) 626 shootings occurred in or around a residence. This total included 54 unintentional shootings, 118 attempted or completed suicides, and 438 assaults/homicides. Thirteen shootings were legally justifiable or an act of self-defense, including three that involved law enforcement officers acting in the line of duty. For every time a gun in the home was used in a self-defense or legally justifiable shooting, there were four unintentional shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides.Guns kept in homes are more likely to be involved in a fatal or nonfatal accidental shooting, criminal assault, or suicide attempt than to be used to injure or kill in self-defense.

BACKGROUND: To describe the incidence and outcome of injuries due to firearms, we conducted a population-based study of fatal and nonfatal gunshot wounds in three cities: Memphis, Tennessee; Seattle; and Galveston, Texas. METHODS: Records of the police, medical examiners, ambulance crews, and hospital emergency departments and hospital admissions were monitored to identify all injuries caused by firearms that were severe enough to prompt emergency medical treatment. These records were linked to generate a complete picture of each event. Census data were used to calculate rates of injury for various population groups. RESULTS: A total of 1915 cases of injury due to firearms were identified between November 16, 1992, and May 15, 1994. The crude rate of firearm injury per 100,000 person-years was 222.6 in Memphis, 143.6 in Galveston, and 54.1 in Seattle. Approximately 88 percent of the injuries were incurred during confirmed or probable assaults; 7 percent were sustained in the course of suicide or attempted suicide; unintentional injuries accounted for 4 percent of the cases. Handguns were used in 88 percent of the cases in which the type of weapon was recorded. Five percent of the 1677 victims who were brought to a hospital emergency department could not be resuscitated; 53 percent were hospitalized, and 42 percent were treated and released. Ninety-seven percent of the deaths occurred within 24 hours of the injury. Emergency department and inpatient charges exceeded $16.5 million. CONCLUSIONS: Injuries due to firearms, most involving handguns, are a major cause of morbidity and mortality in U.S. urban areas. The incidence varies greatly from city to city.

It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period.For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods.During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5).Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.

Central blood flow and cardiac output are increased in most morbidly obese patients. This may be reflected in abnormal vessel sizes. Other influences such as smoking, age, weight, vertebral size, hypertension and age at onset of obesity may also be operative. Abdominal aorta and common iliac artery diameters were retrospectively measured on abdominal computer-assisted axial tomography scans of 44 morbidly obese, vascular disease-free females prior to their bariatric surgery. They were compared at standardized aortic and illiac levels with normal weight, similar age, control patients. There was no correlation between patient body weight, body mass index, per cent excess body weight or age at onset of obesity versus any of the aortic or iliac diameters. Pearson's correlation analysis of smoking, age and hypertension each showed a significant positive relationship with aorto-iliac diameters (p

✓ The authors report the results of a prospective investigation that evaluated postoperative changes in language function after dominant (29 cases) or nondominant (35 cases) anterior temporal lobectomy for treatment of complex partial seizures. These patients received conservative resection of lateral temporal cortex but aggressive resection of medial temporal cortex, None of the patients underwent functional mapping of cortical language ability. All patients were assessed with a standardized aphasia battery (Multilingual Aphasia Examination) before and 6 months after surgery. Postoperatively, the dominant anterior temporal lobectomy group did not show any significant losses in language function compared to patients who underwent nondominant anterior temporal lobectomy. In addition, the dominant temporal lobectomy group showed significant postoperative improvement in complex receptive language comprehension compared to the nondominant group. These results suggest that patients with complex partial seizures of medial temporal lobe onset can undergo a conservative resection of lateral temporal cortex without language mapping. Such surgery carries little risk to language function and provides an excellent postoperative surgical outcome.

✓ Eighty patients underwent anterior corpus callosotomy for treatment of generalized seizures. The patients' mean age was 18.3 years (range 4 to 53 years); the mean age at seizure onset was 5.27 years (range 0.1 to 27 years). The mean intelligence quotient (IQ) of 41 testable patients was 71.12 (range < 30 to 114). The seizure outcome was as follows: 13% were seizure-free, 65% were significantly improved, and 22% were unchanged. Ten patients subsequently underwent a second operation to complete the callosal sectioning which resulted in additional seizure improvement in only five of them. Five complications resulted from 90 operations: two epidural hematomas, one delayed subdural hematoma, one bone-flap infection, and one postcallosotomy disconnection syndrome; two patients died. A younger age at onset of seizures, a higher IQ, and generalized tonic-clonic, atonic, complex-partial, and mixed seizure types were associated with improved seizure outcome.

Context. —While acute alcohol and illicit drug use are common in homicide and suicide victims, the role of chronic substance use in violent death is unclear. Objective. —To measure the magnitude of risk of violent death in the home associated with alcohol use or chronic abuse and use of illicit drugs. Data Sources. —Data obtained from a case-control study of risk factors for homicide and suicide in 3 large metropolitan areas of the United States. Design. —Matched case-control study including 388 homicide cases, 438 suicide cases, and equal numbers of controls matched for age, sex, race, neighborhood, and county. Data were analyzed by means of conditional logistic regressions in which other potential risk factors for violent death were also considered. Outcome and Exposure Measures. —Homicide and suicide victims were identified from medical examiner reports in Shelby County, Tennessee; King County, Washington; and Cuyahoga County, Ohio. Structured interviews were conducted with proxy respondents close to the decedents to obtain information about alcohol or illicit drug use, and history of alcohol-related hospitalization or trouble at work because of drinking by the subject. Data about alcohol use by others living in the same house as the subject were also obtained. Results. —The risks of homicide and suicide associated with alcohol or illicit drug use were elevated, as were the risks of violent death associated with several indicators of chronic alcohol abuse. In addition, nondrinkers living in a home with alcohol users were at increased risk of homicide (odds ratio, 1.7; 95% confidence interval, 0.98-3.0), and non—drug-using individuals residing in homes with illicit drug users were at greatly increased risk of homicide (odds ratio, 11.3; 95% confidence interval, 4.4-28.8). Conclusions. —Alcohol and illicit drug use appear to be associated with an increased risk of violent death. The risk of homicide was increased for non—substance-abusing individuals living in households in which other members abused alcohol or drugs. The concept of the individual at risk of homicide should be broadened to include not only the abuser but also those who may be at risk because of their exposure to others.

Objective. —To determine if failure to achieve return of spontaneous circulation following prehospital advanced cardiac life support (ACLS) warrants termination of efforts at the scene. Design. —Retrospective case series. Setting. —Memphis, Tenn, a city of 610337 people that is served by a fire department—based emergency medical service system. All city ambulances provide ACLS. Patients. —Adult victims of out-of-hospital cardiac arrest due to heart disease. Intervention. —All patients received prehospital ACLS according to the 1986 American Heart Association guidelines. Following prehospital ACLS, all patients were transported to the nearest hospital emergency department whether or not a pulse was restored in the field. Main Outcome Measures. —Survival to hospital admission, survival to hospital discharge, and neurological status at discharge. Results. —Over the 39-month study interval, the Memphis Fire Department treated 1068 victims of out-of-hospital cardiac arrest. Three hundred ten of these (29%) had return of spontaneous circulation prior to transport for some period. The remaining 758 patients (71%) never regained a pulse and were transported with ongoing cardiopulmonary resuscitation. Patients who had return of spontaneous circulation prior to transport were more likely to be admitted (69% vs 7.0%) and far more likely to be discharged alive (26.5% vs 0.4%) than patients who failed to respond to prehospital ACLS. Three patients who survived to hospital discharge despite failure to achieve return of spontaneous circulation prior to emergency medical service transport sustained their cardiac arrest after paramedic arrival. All three were discharged with moderate to severe cerebral disability. Conclusion. —Rapid transport of adults who fail to respond to an adequate trial of prehospital ACLS does not result in meaningful rates of survival. In such cases, on-line emergency medical service physicians should authorize paramedics to cease efforts in the field. ( JAMA . 1993;270:1433-1436)

Pregnancy outcome was followed prospectively in women showing maternal serum alpha-fetoprotein values less than 0.4 multiple of the median. Using a radioimmunoassay later shown by others to produce a disproportionate number of low values, we nonetheless detected all three cases of autosomal trisomy (+18, +18, +21) at amniocentesis in 1531 women screened. Although two fetal losses and two autosomal trisomies (trisomy 18) occurred among a subgroup of only 15 women having two values less than 0.25 multiple of the median, fetal losses were in general far less frequent among the 99 women with at least one maternal serum alpha-fetoprotein value less than 0.4 multiple of the median than among women in previous reports. Comparing women with maternal serum alpha-fetoprotein values less than 0.4 multiple of the median against those with normal values (0.4 to 2.49 multiples of the median) also revealed no significant differences with respect to presence or absence of a variety of antepartum or intrapartum complications. Birth weight, gestational age, arterial cord pH, and Apgar scores also failed to differ significantly (one-way analysis of variance, p greater than 0.05). Women with a viable pregnancy who show low maternal serum alpha-fetoprotein values have a more favorable prognosis than previously claimed.

This paper examines the relationship of coronary-prone behavior pattern, magnitude of recent life change and subsequently reported illnesses in a sample of 145 healthy young adults. Subjects with extreme Type A behavior pattern reported significantly more life changes in the previous year than did other subjects but they reported no more illness in the subsequent surveillance period. Extreme Type A subjects as a group showed no association between recent life changes and illness whereas there was a significant association in subjects without this pattern. The introduction of sex as a control variable does not alter these relationships except for extreme Type A females in whom the magnitude of life change is negatively and significantly correlated with reported illness.

To determine if hypertension during pregnancy in adolescence is associated with subsequently elevated blood pressure (BP), standardized BP was measured in young mothers 3–6 yr after their first pregnancy. In a population of 409 adolescents in a Young Mothers' Program, (age, 13–20; 46% white, 54% black), systolic (S) BP during pregnancy was related to body weight (p < 0.01) but not to race, and 74 women (18%) had hypertension late in pregnancy (HP). Of these women, 63 were studied in follow-up 3–6 yr later; 52 additional young mothers who were normotensive in pregnancy (NP) were randomly selected for comparison. At the time of follow-up mean SBP (115.7 mmHg ± 1.5 S.E.) and diastolic (D) BP (67.9 ± 1.7) of HP were higher (p < 0.01) than SBP (108.8 ± 1.4) and DBF (60.6 ± 1.9) of NP, unrelated to race and body size. SBP, but not DBP, of women taking oral contraceptive agents was higher than SBP of women who were not (p < 0.01), and highest SBP occurred in HP women on oral contraceptives (119.9 ± 2.1). Children's (age 3–6) SBP correlated with mothers' SBP (p < 0.005), and SBP of HP children (97.6 ± 1.3) was higher (p < 0.03) than that of NP children (93.1 ± 1.5). In summary, in adolescent primparous women, a history of hypertension late in pregnancy was associated with increased body weight and with higher blood pressures in both mothers and their children 3–6 yr later. Oral contraceptive usage was associated with increased SBP in both HP and NP, and highest SBP occurred in HP on oral contraceptives.

Summary This study analyzed the effects of heart weights, myocardial fibrosis, sex, and body length upon the duration of the QRS complex. A positive correlation was found between presence or absence of fibrosis and duration of the QRS complex. A positive correlation was also found between weights of the heart and QRS duration, but this correlation appeared to be spurious and due to the tendency of fibrosed hearts to be heavier than those with normal myocardium.

We have carried out a randomized phase III study in 105 patients with advanced non-small cell lung cancer, comparing a four-drug cisplatin-mitomycin-based combination chemotherapy regimen to sequential single-agent therapy. The combination chemotherapy regimen consisted of mitomycin C (10 mg/m2), vinblastine (5 mg/m2), methotrexate (40 mg/m2), and cisplatin (40 mg/m2) given every 28 days. Sequential single-agent chemotherapy consisted of mitomycin C (10 mg/m2) monthly until progression followed by vinblastine (5 mg/m2) every 2 weeks until progression followed by methotrexate (40 mg/m2) weekly until relapse. Patients failing either regimen were followed with supportive care. The objective response rate for the sequential single-agent therapy was 19% versus 25% for the combination chemotherapy group (P greater than .5). The median survival for the single-agent group was 166 days and 191 days for the combination chemotherapy group. Overall survival was not statistically different between the two groups (P greater than .5). Leucopenia, anemia, and prolonged anorexia with nausea and vomiting were more common in the combination chemotherapy group compared to the single-agent group. This study failed to demonstrate a sufficient therapeutic benefit in the face of the added toxicity for the combination chemotherapy regimen compared to sequential single-agent therapy.

Twelve single-nucleotide polymorphisms (SNPs) in the human gamma-aminobutyric acid type B (GABA(B)) receptor subunit 2 gene (GABAB2) were tested for association with nicotine dependence (ND) in an extensively phenotyped cohort of 1,276 smokers and nonsmokers, representing approximately 404 nuclear families of African American (AA) or European American (EA) origin. The GABAB2 gene encodes a subunit of the GABA(B) receptor for GABA, an inhibitory neurotransmitter involved in the regulation of many physiological and psychological processes in the brain. The gene is located within a region of chromosome 9q22 that showed a "suggestive" linkage to ND. Individual SNP analysis performed using the PBAT-GEE program indicated that two SNPs in the AAs and four SNPs in the EAs were significantly associated with ND. Haplotype analysis using the Family-Based Association Test revealed that, even after Bonferroni correction, the haplotype C-C-G of rs2491397-rs2184026-rs3750344 had a significant positive association with ND in both the pooled and the AA samples. In the EAs, we identified two haplotypes, C-A-C-A and T-A-T-A, formed by SNPs rs1435252-rs378042-rs2779562-rs3750344, that showed a highly significant negative and positive association with ND, respectively. In summary, our findings provide evidence of a significant association of GABAB2 variants with ND, implying that this gene plays an important role in the etiology of this drug addiction.

Epidemiological studies have demonstrated that genetic factors account for at least 50% of the liability for nicotine dependence (ND). Although several linkage studies have been conducted, all samples to date were primarily of European origin. In this study, we conducted a genomewide scan of 1,261 individuals, representing 402 nuclear families, of African American (AA) origin. We examined 385 autosomal microsatellite markers for ND, which was assessed by smoking quantity (SQ), the Heaviness of Smoking Index (HSI), and the Fagerstrom Test for ND (FTND). After performing linkage analyses using various methods implemented in the GENEHUNTER and S.A.G.E. programs, we found a region near marker D10S1432 on chromosome 10q22 that showed a significant linkage to indexed SQ, with a maximum LOD score of 4.17 at 92 cM and suggestive linkage to HSI, SQ, and log-transformed SQ. Additionally, we identified three regions that met the criteria for suggestive linkage to at least one ND measure: on chromosomes 9q31 at marker D9S1825, 11p11 between markers D11S1993 and D11S1344, and 13q13 between markers D13S325 and D13S788. Other locations on chromosomes 15p11, 17q25, and 18q12 exhibited some evidence of linkage for ND (LOD >1.44). The four regions with significant or suggestive linkage were positive for multiple ND measures by multiple statistical methods. Some of these regions have been linked to smoking behavior at nominally significant levels in other studies, which provides independent replication of the regions for ND in different cohorts. In summary, we found significant linkage on chromosome 10q22 and suggestive linkage on chromosomes 9, 11, and 13 for major genetic determinants of ND in an AA sample. Further analysis of these positive regions by fine mapping and/or association analysis is thus warranted. To our knowledge, this study represents the first genomewide linkage scan of ND in an AA sample.

Perinatal asphyxia and intracranial hemorrhage are known to be major determinants of neurodevelopmental outcome in VLBW neonates, but specific and accurate predictors are not well established. Recent investigations have indicated that serum creatine kinase isoenzyme BB (CK-BB) levels are associated with outcome.

Decreased blood flow velocity (increased pulsatility index, PI) in the anterior cerebral arteries (ACA) has been reported in preterm infants with intraventricular hemorrhage. From Feb. 1982 to Aug. 1983, we prospectively evaluated PI, cranial ultrasound and neurologic status (Sarnat Score), in 60 infants ⩽32 weeks gestation on days 1, 3 and 7 and then weekly until discharge, to determine their correlation with PI. PI was calculated from the tracings obtained by doppler ultrasound by the method described by Bada et al. Survival, neurologic status (Sarnat Score), cranial ultrasound, occurrence of seizures, and discharge neurologic examination (Parmalee exam) were assessed. Mean B.Wt. was 1151 grams (640-1750) and mean GA was 30.1 weeks (26-32). There were 31 males and 29 females. Mean Apgar Score at 1 minute was 4.7 and at 5 minutes was 6.6. Forty-two of the infants were inborn. The maximum PI recorded on day 1 correlated negatively with B.Wt. (p

In a prospective study of factors which may predict neurologic outcome in VLBW infants, complete observations were collected on 84 preterm infants of < 32 weeks gestation. Cranial ultrasound (US.) was performed on days 1 and 3. The studies on day 3 better predicted outcome and will be described. US. were scored as "Normal" (normal, suspect, or mild ICH) or "Severe" (IVH with dilated ventricles or parenchymal blood). US. scores were compared with: neurologic status in the first week, occurence of seizures, development of hydrocephalus, discharge neurologic status, and mortality. Mean B.Wt. was 1229 gm, and mean GA was 30.3 weeks. 73 infants had "Normal" US., and 11 had "Severe" US. "Severe" US. correlated with low B.Wt. (p⩽.01), and low 5 minute Apgar score (p⩽.005), but not with GA or 1 minute Apgar score. US. did not correlate with development of hydrocephalus, or abnormal discharge neurologic status. The following outcomes correlated with day 3 US.: The infants are being followed to evaluate whether US. predicts long-term neurologic outcome.

CSF LDH is elevated in neonatal IVH and may arise from cerebral injury (Engelke, 1983). To test the value of CSF LDH in detecting cerebral injury, a prospective study was carried out in 57 neonates ≤ 32 weeks gestation. Total CSF LDH and its isoenzymes were measured on admission and cranial ultrasound (US) was performed on day 1 and 3. Ultrasounds were graded normal, small-moderate IVH, moderate-large IVH with ventricular dilation or parenchymal extension. There was a significant correlation of CSF LDH with severity of US hemorrhage (p

A-NEONATAL STATUS SCORE OF TRANSPORTED NEWBORNS AS A PREDICTOR OF TERM MORBIDITY AND MORTALITY