Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose

Importance

Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.

Objective

To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.

Design, Setting, and Participants

This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.

Exposure

Hospital OORP implementation.

Main Outcomes and Measures

The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.

Results

A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.

Conclusions and Relevance

In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

The impact of abortion bans on short-term housing needs

OBJECTIVES

State-level abortion bans in the United States have created a complex legal landscape that forces many prospective patients to travel long distances to access abortion care. The financial strain and logistical difficulties associated with travelling out of state for abortion care may present an insurmountable barrier to some individuals, especially to those with limited resources. Tracking the impact of these abortion bans on travel and housing is crucial for understanding abortion access and economic changes following the Dobbs U.S. Supreme Court decision.

STUDY DESIGN

This study used occupancy data from an average of 2,349,635 (standard deviation = 111,578) U.S. Airbnb listings each month from October 1st, 2020, through April 30th, 2023, to measure the impact of abortion bans on travel for abortion care and the resulting economic effects on regional economies.

METHODS

The study used a synthetic difference-in-differences design to compare monthly-level occupancy rate data from 1-bedroom entire-place Airbnb rentals within a 30-min driving distance of abortion clinics in states with and without abortion bans.

RESULTS

The study found a 1.4 percentage point decrease in occupancy rates of Airbnbs around abortion clinics in states where abortion bans were in effect, demonstrating reductions in Airbnb use in states with bans. In the 6-month period post Dobbs, this decrease translates to 16,548 fewer renters and a $1.87 million loss in revenue for 1-bedroom entire-place Airbnbs within a 30-min catchment area of abortion facilities in states with abortion restrictions.

CONCLUSION

This novel use of Airbnb data provides a unique perspective on measuring demand for abortion and healthcare services and demonstrates the value of this data stream as a tool for understanding economic impacts of health policies.

Access to Hepatitis C Treatment during and after Incarceration in New Jersey, United States: A Qualitative Study

Despite effective antiviral therapy for hepatitis C virus (HCV), people who are incarcerated and those returning to the community face challenges in obtaining HCV treatment. We aimed to explore facilitators and barriers to HCV treatment during and after incarceration. From July-November 2020 and June-July 2021, we conducted 27 semi-structured interviews with residents who were formerly incarcerated in jail or prison. The interviews were audio-recorded and professionally transcribed. We used descriptive statistics to characterize the study sample and analyzed qualitative data thematically using an iterative process. Participants included five women and 22 men who self-identified as White (n = 14), Latinx (n = 8), and Black (n = 5). During incarceration, a key facilitator was having sufficient time to complete HCV treatment, and the corresponding barrier was delaying treatment initiation. After incarceration, a key facilitator was connecting with reentry programs (e.g., halfway house or rehabilitation program) that coordinated the treatment logistics and provided support with culturally sensitive staff. Barriers included a lack of insurance coverage and higher-ranking priorities (e.g., managing more immediate reentry challenges such as other comorbidities, employment, housing, and legal issues), low perceived risk of harm related to HCV, and active substance use. Incarceration and reentry pose distinct facilitators and challenges to accessing HCV treatment. These findings signal the need for interventions to improve engagement in HCV care both during and after incarceration to assist in closing the gap of untreated people living with HCV.

Association of death or illness from COVID-19 among family and friends on vaccine uptake within four months of the Emergency Use Authorization. Findings from a national survey in the United States

OBJECTIVE

To examine the relationship between knowing that a friend or family member became ill with, or died from, COVID-19 and receiving a vaccine dose within four months of the FDA's Emergency Use Authorization.

METHODS

A national sample of 1,517 respondents were surveyed from April 7 to April 12, 2021, 1,193 of whom were eligible for the vaccine when the data were collected.

RESULTS

Respondents who knew someone who became ill with COVID-19 (AOR = 2.32, 95 % CI 1.74-3.09) or knew someone who died (AOR = 2.29, 95 % CI 1.32-3.99) from COVID-19 were more likely to receive at least a single COVID-19 vaccine dose.

CONCLUSION

Encouraging people to share their COVID-19 illness and bereavement experiences with their local network such as friends, families, social-networks and via social media might help increase vaccine uptake.

Abstract A140: Factors associated with receipt of guideline-concordant treatment among Medicaid enrollees with breast and colorectal cancer

Purpose: Medicaid enrollees with cancer are less likely to receive treatment consistent with established guidelines. It remains unclear what specific factors are associated with non-receipt or delays in guideline-concordant cancer care among Medicaid patients. In this study, we examine receipt of guideline-concordant Medicaid enrollees with breast or colorectal cancer. Methods: We linked data from the New Jersey State Cancer Registry and Medicaid claims and encounter files for patients diagnosed with a first primary breast (BC) or colorectal (CRC) cancer from 2011-2015. We assess guideline-concordant treatment using National Comprehensive Cancer Network and American Society of Clinical Oncology criteria, which include endocrine therapy within 1 year, radiation therapy within 1 year, and adjuvant chemotherapy within 120 days for BC patients; and, postoperative chemotherapy within 9 months, radiation therapy within 6 months, and adjuvant chemotherapy within 4 months for CRC patients that fit the specific clinical criteria for each guideline. For each guideline, patients were placed in one of the three categories: 1.) on-time concordant care, 2.) delayed concordant care, 3.) non-receipt of concordant care. Delayed concordant care included patients with guideline-directed care outside of the indicated timeframe. We used multivariate ordinal logistic regression to determine the independent effects of demographic, health care utilization, and Medicaid enrollment factors on the 3-level concordance measure. Results: Rates of guideline concordant care were: 69.5% for BC endocrine therapy, 63.4% for BC radiation therapy, 76.4% for BC adjuvant chemotherapy, 69.4% for CRC postoperative chemotherapy, 91.9% for CRC radiation therapy, and 68.4% for CRC adjuvant chemotherapy. An additional 10.1% of BC patients received delayed care for endocrine therapy. An additional 14.1% of CRC patients received delayed care for postoperative chemotherapy. Ordinal logit models showed BC patients enrolled through the New Jersey Cancer Education and Early Detection program had a 29.3 percentage point higher probability of on-time care for endocrine therapy compared to women not enrolled through the program (p<0.001). CRC patients enrolled in managed care compared to fee-for-service had a 44 percentage point higher probability for receiving guideline concordant adjuvant chemotherapy (p<0.001). For a subset of BC and CRC guidelines we observed Hispanic patients had lower probably of receiving delayed or non-concordant care compared to NH-White patients (p<0.05). Conclusions: We identified several demographic and enrollment predictors of delayed guideline-concordant treatment for low-income cancer patients. These findings can inform providers to prioritize the targeting of care management resources for patients at high risk for not meeting treatment guidelines and highlight.

Citation Format: Jennifer Tsui, Derek DeLia, Jose Nova, Antoinette Stroup, Dawn L. Hershman, Joel Cantor. Factors associated with receipt of guideline-concordant treatment among Medicaid enrollees with breast and colorectal cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A140.

Abstract C018: Racial disparities in health care utilization at the end of life among New Jersey Medicaid beneficiaries with advanced cancer

PURPOSE: Quality of cancer care experienced by Medicaid beneficiaries near the end-of-life (EOL) is not well understood. Measures endorsed by national organizations discourage aggressive EOL care and encourage timely referrals to hospice care. We sought to 1) assess the prevalence of aggressive EOL care and hospice enrollment for Medicaid beneficiaries with advanced cancer, and 2) determine whether racial/ethnic disparities exist in patterns of EOL care. METHODS: We used a New Jersey State Cancer Registry-Medicaid claims linked dataset to identify Medicaid beneficiaries (ages 21-64) diagnosed with stage IV breast and colorectal cancer from 2011-2015 and died by January 2016. We measured aggressive EOL care using the four measures: >1 hospitalization, >1 emergency department (ED), any intensive care unit (ICU) admission in the last 30 days before death; receipt of chemotherapy in the last 14 days before death; and a composite measure for “any aggressive care” using the four measures described. We measured hospice enrollment after diagnosis, and hospice enrollment in the last 3 days of life. We used descriptive statistics and multivariate logistic regression models to assess the relationship between race/ethnicity and outcome measures (i.e., rates of aggressive EOL care and hospice use). We adjusted for sex, age at diagnosis, year of diagnosis, length of survival, cancer type, comorbidities, and Medicaid managed care status. RESULTS: We identified 349 patients diagnosed with stage IV breast and colorectal cancer. More than half (56%) identified as a racial/ethnic minority, including 33% Non-Hispanic (NH) Blacks, 18% Hispanics, and 5% NH-Asian Pacific Islanders. Nearly two-thirds of patients (62%) received at least one measure of aggressive EOL care. Almost one-third had >1 hospitalization (27%), >1 ED visit (31%), or were admitted to the ICU (30%) in the last 30 days of life; or received chemotherapy (34%) in the last 14 days of life. Compared to NH-Whites, NH-Blacks had higher odds of receiving any aggressive EOL care (aOR 1.87, 95% CI: 1.08-3.26), >1 hospitalization (aOR 1.98, 95% CI: 1.13-3.47), and >1 ED visit (aOR 1.79, 95% CI: 1.05-3.06), after adjusting for other demographic and tumor characteristics. Among all patients, only 39% of patients enrolled in hospice, while 14% enrolled in hospice in the last 3 days of life. No significant differences in hospice enrollment were observed by race/ethnicity in the multivariate models. CONCLUSION: The majority of Medicaid patients with advanced cancer received aggressive EOL care and did not enroll in hospice. Although all patients in our study were Medicaid beneficiaries, NH-Blacks were twice as likely to receive aggressive EOL care compared to NH-Whites. These racial/ethnic disparities suggest further work is warranted, particularly in larger datasets with greater numbers of diverse cancer patients, to understand the multilevel processes beyond socioeconomic or health insurance status, that lead to suboptimal EOL care.

Citation Format: Annie W Yang, David Goldin, Jose Nova, Jyoti Malhotra, Joel Cantor, Jennifer Tsui. Racial disparities in health care utilization at the end of life among New Jersey Medicaid beneficiaries with advanced cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C018.

The reliability and validity of the SF-36 health survey questionnaire for use with individuals with traumatic brain injury

In order to examine the reliability and validity of the SF-36 for use with individuals with TBI, the SF-36 and three measures of health-related problems in persons with TBI (BDI-II, TIRR Symptom Checklist, Health Problems List) were administered to 271 individuals without a disability, 98 individuals with mild TBI, and 228 individuals with moderate-severe TBI. Internal consistency (reliability) was demonstrated for all SF-36 scales. Significant correlations were found between the SF-36 scales and the other measures, with stronger correlations emerging in the TBI groups. The TBI groups obtained significantly lower SF-36 scores than the comparison group, and the mild TBI group scored lower than the moderate-severe group. For the most part, the differences between the TBI groups disappeared when BDI-II scores were controlled for. These findings suggest that the SF-36 is a reliable and valid measure for use with persons with TBI.

Analysis of selection effects in New York City's Medicaid managed care population prior to mandatory enrollment

It is becoming increasingly apparent that over the next several years the majority of Medicaid patients in many states will become enrolled in managed care plans, some voluntarily, but most as the result of mandatory initiatives. An important issue related to this development is the extent to which this movement to managed care is accompanied by serious selection effects, either across the board during the phase in or among individual plans or plan types with full-scale implementation. This paper examines selection effects in New York City between 1993 and 1997 during the voluntary enrollment period prior to implementation of mandatory enrollment pursuant to a Section 1115 waiver. No substantial selection bias was documented between patients entering managed care and those remaining in the fee-for-service system among the largest rate groups, although some selection effect was found among plans and plan types (with investor-owned plans enrolling patients with lower prior utilization and expenses).

Media violence

Research on the effects of media violence is not well understood by the general public. Despite this fact, there is an overwhelming consensus in the scientific literature about the unhealthy effects of media violence. Meta-analyses show that media-violence viewing consistently is associated with higher levels of antisocial behavior, ranging from the trivial (imitative violence directed against toys) to the serious (criminal violence), with many consequential outcomes in between (acceptance of violence as a solution to problems, increased feelings of hostility, and the apparent delivery of painful stimulation to another person). Desensitization is another well-documented effect of viewing violence, which is observable in reduced arousal and emotional disturbance while witnessing violence, the reduced tendency to intervene in a fight, and less sympathy for the victims of violence. Although there is evidence that youth who are already violent are more likely to seek out violent entertainment, there is strong evidence that the relationship between violence viewing and antisocial behavior is bidirectional. There is growing evidence that media violence also engenders intense fear in children which often lasts days, months, and even years. The media's potential role in solutions to these problems is only beginning to be explored, in investigations examining the uses and effects of movie ratings, television ratings, and the V-chip, and the effects of media literacy programs and public education efforts. Future research should explore important individual differences in responses to media violence and effective ways to intervene in the negative effects.

Confabulation, memory deficits, and frontal dysfunction

This paper explores potential cognitive deficits underlying confabulation of patient, G.S., following an anterior communication artery aneurysm. G.S.'s performance on tasks assessing memory for temporal duration, temporal order, and speaker identification is examined as is his recollection of autobiographical events. We compare G.S. with three nonconfabulating patients matched with him for age, education, and neuropsychological measures of memory and frontal deficits and with three age- and education-matched control subjects. Like frontal control patients, G.S. underestimated temporal durations and showed poor source monitoring (speaker identification). In addition, G.S. showed an even more pronounced deficit in recall of autobiographical memories and relatively more detailed reports of laboratory-induced memories for imagined events. We suggest that this configuration of deficits rather than any single factor accounts for G.S.'s tendency to confabulate.

Performance but not acquisition of skill learning is severely impaired in the elderly

A battery of cognitive tests, specifically designed to assess verbal and skill learning, was administered to healthy volunteer subjects of different ages. Although there were age-related declines in initial and terminal performance in both a pursuit rotor and a mirror reading task, the increase in performance with practice on these tasks was little affected by age. Recall, but not recognition, of verbal material was also impaired in the elderly, as were some measures of frequency estimation. These findings are compatible with the contention that, although acquisition of declarative tasks, which requires conscious processing, is impaired in the elderly, acquisition of nondeclarative tasks, which can be learned without conscious awareness, is not affected by age. However, classical conditioning may be an exception to this generalization for reasons that are at the present time unknown.

Full-time attending physician coverage in a pediatric emergency department. Effect on risk management

OBJECTIVE

To determine the effect on risk management of full-time attending physician coverage in a pediatric emergency department.

DESIGN

Retrospective, with data collected through a review of malpractice cases from August 1, 1984 through July 31, 1990.

SETTING

Large urban teaching hospital's pediatric emergency department.

RESULTS

Malpractice cases from August 1, 1984 to July 31, 1987, when there was part-time attending physician coverage, were compared with those of 1987 through 1990, when full-time attending physician coverage was instituted. Medical records from the pediatric emergency department, subsequent hospital records, and abstracts of claims were reviewed. Disbursements and the types of lawsuits were also analyzed. There was a 41.7% decrease in the number of claims filed and a 44.3% reduction in payments with full-time coverage.

CONCLUSIONS

Full-time attending physician coverage in a pediatric emergency department was associated with a decrease in the number of malpractice claims and the amounts of disbursements. Further research in this area on a larger study sample is advisable.

Concomitant eyeblink and heart rate classical conditioning in young, middle-aged, and elderly human subjects

Pavlovian heart rate (HR) and eyeblink (EB) conditioning were assessed in 4 groups of Ss who differed in age: young = 19-33 years, young middle-aged = 35-48 years, old middle-aged = 50-63 years, and old = 66-78 years. A 100-ms corneal airpuff was the unconditioned stimulus and a 600-ms tone was the conditioned stimulus. A nonassociative control group received explicitly unpaired tone and airpuff presentations. All Ss were studied for 2 100-trial sessions separated by approximately 7 days. An impairment in acquisition of both the EB and HR responses occurred in the old and middle-age Ss, but all age groups showed significantly greater conditioning than did the control group. Slight increases in performance resulted from a 2nd session of training. These findings suggest an age-related impairment in a general associative process.

Antisocial traits as modifiers of treatment response in borderline inpatients

The relationship of antisocial traits to treatment response in 35 female inpatients with borderline personality disorder was studied. Antisocial traits were measured with the Personality Assessment Inventory. Treatment response was measured by weekly ratings on the Symptom Checklist-90-Revised over 25 weeks of hospitalization. Treatment course was found to be significantly associated with the level of antisocial behavior reported at admission.

Concomitant eyeblink and heart rate classical conditioning in young, middle-aged, and elderly human subjects

Pavlovian heart rate (HR) and eyeblink (EB) conditioning were assessed in 4 groups of Ss who differed in age: young = 19-33 years, young middle-aged = 35-48 years, old middle-aged = 50-63 years, and old = 66-78 years. A 100-ms corneal airpuff was the unconditioned stimulus and a 600-ms tone was the conditioned stimulus. A nonassociative control group received explicitly unpaired tone and airpuff presentations. All Ss were studied for 2 100-trial sessions separated by approximately 7 days. An impairment in acquisition of both the EB and HR responses occurred in the old and middle-age Ss, but all age groups showed significantly greater conditioning than did the control group. Slight increases in performance resulted from a 2nd session of training. These findings suggest an age-related impairment in a general associative process.

Working-memory capacity as long-term memory activation: an individual-differences approach

One explanation of the correlation often observed between working-memory span scores and reading comprehension is that individuals differ in level of activation available for long-term memory units. Two experiments used the fan manipulation to test this idea. In Experiment 1, high- and low-working-memory Ss learned a set of unrelated sentences varying in the number of shared concepts (fan) and then performed speeded recognition for those sentences. Low-working-memory Ss showed a larger increase in recognition time as fan increased. When the slope of the fan effect was partialed out of the relationship between working-memory span and verbal abilities, the relationship was reduced to nonsignificance. In Experiment 2, Ss learned thematically related sentences that varied in fan. Low-span Ss showed the positive fan effect typically found with thematically unrelated sentences, whereas high-span Ss showed a negative fan effect. The results are discussed in terms of a general capacity theory.

Individual differences in working memory and comprehension: a test of four hypotheses

A relationship has consistently been found between measures of working memory and reading comprehension. Four hypotheses for this relationship were tested in 3 experiments. In the first 2 experiments, a moving window procedure was used to present the operation-word and reading span tasks. High- and low-span subjects did not differentially trade off time on the elements of the tasks and the to-be-remembered word. Furthermore, the correlation between span and comprehension was undiminished when the viewing times were partialed out. Experiment 3 compared a traditional experimenter-paced simple word-span and a subject-paced span in their relationship with comprehension. The experimenter-paced word-span correlated with comprehension but the subject-paced span did not. The results of all 3 experiments support a general capacity explanation for the relationship between working memory and comprehension.

Individual differences in working memory and comprehension: A test of four hypotheses

A relationship has consistently been found between measures of working memory and reading comprehension. Four hypotheses for this relationship were tested in 3 experiments. In the first 2 experiments, a moving window procedure was used to present the operation-word and reading span tasks. High- and low-span subjects did not differentially trade off time on the elements of the tasks and the to-be-remembered word. Furthermore, the correlation between span and comprehension was undiminished when the viewing times were partialed out. Experiment 3 compared a traditional experimenter-paced simple word-span and a subject-paced span in their relationship with comprehension. The experimenter-paced word-span correlated with comprehension but the subject-paced span did not. The results of all 3 experiments support a general capacity explanation for the relationship between working memory and comprehension.

The influence of concurrent load on mouthed and vocalized modality effects

A visual search task was coupled with the serial recall of words to assess the extent to which modality effects mediated by vocalizing and silent mouthing reflect an automatically activated preattentive process. Overall, serial position functions systematically changed as concurrent task demands increased, but the magnitude of the modality effect associated with both mouthing and vocalizing was not altered, regardless of whether or not subjects simultaneously searched for digits. These results support the notion that modality effects index a preattentive process that can be activated automatically by either spoken input or gestural cues associated with speech.

Modality effects: do they fall on deaf ears?

The present study tests the assumption of the PAS theory of echoic memory (Greene & Crowder, 1984) that the representation of acoustic features is necessary in producing modality effects. Performance by deaf subjects was compared to hearing subjects on serial and free-recall tasks with vocalizing and non-vocalizing conditions. For the serial tasks, typical modality and acoustic similarity effects were observed with hearing subjects, and no such effects were found with deaf subjects. However, for the free-recall task, modality effects were found for both deaf and hearing subjects. It is unlikely that phonological coding resulting from gestural cues mediates the modality effect, as phonological confusion errors for deaf and hearing subjects did not correlate with the size of this effect.

Mechanism of mouse skin tumor promotion by chrysarobin

The skin tumor-promoting ability of 1,8-dihydroxy-3-methyl-9-anthrone (chrysarobin) was compared with that of 12-O-tetradecanoylphorbol-13-acetate (TPA) and 1,8-dihydroxy-9-anthrone (anthralin) in SENCAR mice. Although dose-response comparisons indicated that chrysarobin was several orders of magnitude less potent than TPA for promoting papilloma formation, this anthrone was 1.5 to 2 times more potent than anthralin. Maximal papilloma responses were achieved by 15 weeks of promotion with TPA whereas at least 25 weeks of promotion were necessary to achieve maximal papilloma responses with chrysarobin or anthralin indicating marked differences in tumor latency between the two classes of compounds. Interestingly, at optimal promoting doses, chrysarobin gave a carcinoma response (22% with 0.3 carcinomas per mouse at 45 weeks) similar to that of TPA suggesting that this compound may be more efficient at promoting carcinomas than papillomas. In two-stage promotion experiments, chrysarobin was incapable of functioning independently as a Stage I or II promoter despite its complete promoting activity. Chrysarobin and TPA were compared at optimal promoting doses for their ability to induce: (a) skin edema, (b) epidermal hyperplasia, and (c) epidermal ornithine decarboxylase. In each case, distinct differences were noted between the two compounds. When taken together, the data support the hypothesis that anthracene-derived skin tumor promoters work at least in part by a mechanism different from the phorbol esters.

Developmental differences in empathy with a television protagonist's fear

An experiment was conducted to determine whether children at different ages (3-5 vs 9-11) differ in their tendency to share the emotion of a television character. Subjects were shown a videotape of either a frightening stimulus alone or a character's fear in response to a threatening stimulus that was suggested rather than shown directly. Contrasting predictions were made based on a cognitive-developmental view of the process of empathy vs an automatic conception. Both self-reported emotional reactions and physiological responses were consistent with the cognitive-developmental approach: The younger children were less emotionally aroused by the character's fear than by the fear-provoking stimulus, while the older children responded emotionally to both versions of the videotape. The younger children's lack of empathy was not due to a failure to recognize the nature of the character's emotion. There was some evidence that the older children exhibited a greater tendency to role take than did the younger children.

Flow murmur associated with partial occlusion of the right pulmonary artery

An 18-year-old male student presented with a brief history of syncope followed by shortness of breath with exertion, and the development of murmur over the right chest. The symptoms and murmurs were related to a pulmonary embolus which partially occluded the right pulmonary artery and its major branches. The murmur gradually diminished and disappeared when right pulmonary perfusion had almost returned to normal as determined by lung scan. The association of pulmonic flow murmurs and pulmonary emboli is reviewed.