Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Mismatch between self-perceived and calculated cardiometabolic disease risk among participants in a prevention program for cardiometabolic disease: a cross-sectional study

Background

The rising prevalence of cardiometabolic diseases (CMD) calls for effective prevention programs. Self-assessment of CMD risk, for example through an online risk score (ORS), might induce risk reducing behavior. However, the concept of disease risk is often difficult for people to understand. Therefore, the study objective was to assess the impact of communicating an individualized CMD risk score through an ORS on perceived risk and to identify risk factors and demographic characteristics associated with risk perception among high-risk participants of a prevention program for CMD.

Methods

A cross-sectional analysis of baseline data from a randomized controlled trial conducted in a primary care setting. Seven thousand five hundred forty-seven individuals aged 45–70 years without recorded CMD, hypertension or hypercholesterolemia participated. The main outcome measures were: 1) differences in cognitive and affective risk perception between the intervention group - who used an ORS and received an individualized CMD risk score- and the control group who answered questions about CMD risk, but did not receive an individualized CMD risk score; 2) risk factors and demographic characteristics associated with risk perception.

Results

No differences were found in cognitive and affective risk perception between the intervention and control group and risk perception was on average low, even among high-risk participants. A positive family history for diabetes type 2 (β0.56, CI95% 0.39–0.73) and cardiovascular disease (β0.28, CI95% 0.13–0.43), BMI ≥25 (β0.27, CI95% 0.12–0.43), high waist circumference (β0.25, CI95% 0.02–0.48) and physical inactivity (β0.30, CI95% 0.16–0.45) were positively associated with cognitive CMD risk perception in high-risk participants. No other risk factors or demographic characteristics were associated with risk perception.

Conclusions

Communicating an individualized CMD risk score did not affect risk perception. A mismatch was found between calculated risk and self-perceived risk in high-risk participants. Family history and BMI seem to affect the level of CMD risk perception more than risk factors such as sex, age and smoking. A dialogue about personal CMD risk between patients and health care professionals might optimize the effect of the provided risk information.

Trial registration

Dutch trial Register number NTR4277, registered 26th Nov 2013.

Changes in the expression of calcitonin gene-related peptide after exposure to injurious stretch-shortening contractions

One of the factors that can result in musculoskeletal injuries, and time off work, is exposure to repetitive motion. The goal of this study was to determine if skeletal muscle injury induced by exposure to injurious stretch-shortening cycles (iSSCs), resulted in hyperalgesia in the hind limb and changes in calcitonin-gene related peptide (CGRP) immunolabeling in the dorsal root ganglia (DRG) in young and old male rats.

METHODS

Young (3months) and old (30months) male Fisher 344×BN F1 rats were anesthetized with isoflurane and the left hind limbs were exposed to 15 sets of 10 SSCs. Control animals were exposed to a single bout of SSCs of equal intensity. Sensitivity to mechanical stimulation was assessed using von Frey filaments prior to beginning the experiment, and on days 2 and 9 following exposure to iSSCs. Rats were euthanized one, 3 or 10days after the exposure. The ipsilateral DRG were dissected from the L4-5 region of the spine, along with the left tibialis anterior (LTA) muscle.

RESULTS

Rats exposed to iSSCs were more sensitive to mechanical stimulation than control rats 2days after the exposure, and showed a reduction in peak force 3days after exposure. Changes in sensitivity to pressure were not associated with increases in CGRP labeling in the DRG at 3days. However, 9days after exposure to iSSCs, old rats still displayed an increased sensitivity to mechanical stimulation, and this hyperalgesia was associated with an increase in CGRP immunolabeling in the DRG. Young rats exposed to iSSC did not display a change in CGRP immunolabeling and sensitivity to mechanical stimulation returned to control levels at 10days.

CONCLUSIONS

These findings suggest that hyperalgesia seen shortly after exposure to iSSC is not influenced by CGRP levels. However, in cases where recovery from injury may be slower, as it is in older rats, CGRP may contribute to the maintenance of hyperalgesia.

Unrecognized myocardial infarction and the risk of stroke: The Rotterdam Study

OBJECTIVE

To investigate the relationship between unrecognized myocardial infarction and the risk of stroke in a population-based cohort study.

METHODS

We followed 6,439 participants from the Rotterdam Study for stroke until January 2002. Participants were free from stroke, and presence of myocardial infarction was assessed at baseline (1990-1993). We calculated hazard ratios of stroke for persons with unrecognized or recognized myocardial infarction compared with persons without myocardial infarction. Analyses were adjusted for age, sex, and cardiovascular risk factors.

RESULTS

In 52,915 person-years of follow-up, 505 strokes occurred. Recognized myocardial infarction was only borderline associated with an increased risk of stroke. Unrecognized myocardial infarction increased the risk of stroke by 76% (age- and sex-adjusted hazard ratio 1.76, 95% CI 1.31 to 2.37). Stratification by sex showed that the increased risk was only found in men (hazard ratio for men 2.53, 95% CI 1.68 to 3.81; hazard ratio for women 1.27, 95% CI 0.82 to 1.96). After adjusting for cardiovascular risk factors at baseline, the risk remained significantly increased in men (hazard ratio for stroke 2.13, 95% CI 1.35 to 3.36). Subtyping of strokes revealed that unrecognized myocardial infarction was particularly associated with cortical ischemic strokes (hazard ratio for men 3.57, 95% CI 1.79 to 7.12).

CONCLUSIONS

Men with unrecognized myocardial infarction have an increased risk of stroke.

Renal transplantation in the elderly — the Irish experience

BACKGROUND

The aim of this paper was to evaluate patient and kidney graft survival rates in renal transplant recipients and compare the outcomes between the different patient age groups.

METHODS

A retrospective review of all adult renal transplants performed at Beaumont Hospital between the years 1986-2001 was carried out. Patients were defined as 'elderly' if they were 65 years of age or older and 'younger' if less than 65 years at the time of transplantation. Patient and transplant graft survival rates were analysed for each age group.

RESULTS

Data were analysed on 1462 'younger' patients and 105 'elderly' renal transplant recipients. Estimated patient survival at 1, 5 and 10 years were 96%, 87% and 74% in the younger patient group compared to 85%, 59% and 33% in the elderly group. The adjusted graft survival rates (adjusted for death due to other causes and with a functioning graft in situ) for the younger group were 89%, 77% and 64% at one, five and ten years respectively, while for the elderly group, adjusted one, five and ten year survival rates were 89%, 83% and 70% respectively.

CONCLUSIONS

Although the elderly have a shorter life expectancy than the younger population they do benefit from renal transplantation similar to the younger recipients.

Dietary antioxidants and the risk of ischemic stroke: The Rotterdam Study

In the Rotterdam Study, the authors investigated whether high intake of antioxidants from food is associated with the risk of stroke. Among 5,197 participants who were followed on average for 6.4 years, 227 ischemic strokes occurred. Higher intake of antioxidants was associated with a lower risk of stroke. The relationship was dose-dependent, significant for vitamin C, and most pronounced in smokers. These results agree with the view that high dietary intake of antioxidants, in particular vitamin C and--in smokers--vitamin E, reduces the risk of stroke.

Comparison between measures of atherosclerosis and risk of stroke: the Rotterdam Study

BACKGROUND AND PURPOSE

Several measures of atherosclerosis predict the risk of stroke. However, a comparison between various measures of atherosclerosis is lacking, and limited information exists on the added value of individual measures of atherosclerosis to cardiovascular risk factors. We compared different measures of atherosclerosis in relation to stroke.

METHODS

The study was based on the prospective cohort of the Rotterdam Study and included 6913 participants who did not suffer from previous stroke. At baseline, carotid intima-media thickness and plaques, ankle-arm index, and aortic calcifications were assessed; 3996 participants (53%) had measures of all studied markers of atherosclerosis. After a mean follow-up of 6.1 years, 378 strokes occurred. Data were analyzed with Cox proportional-hazards regression and Akaike information criteria scores.

RESULTS

Carotid intima-media thickness and aortic calcifications were related most strongly to the risk of stroke (relative risk, 2.23 and 1.89; 95% confidence interval, 1.48 to 3.36 and 1.28 to 2.80 for highest versus lowest tertile, respectively). The relations between intima-media thickness, aortic calcifications, and carotid plaques and stroke remained after adjustment for cardiovascular risk factors. Intima-media thickness and aortic calcifications were related to the risk of stroke independently of each other. The relation between ankle-arm index and stroke disappeared after adjustment for cardiovascular risk factors.

CONCLUSIONS

Carotid intima-media thickness and aortic calcifications are stronger predictors of incident stroke than carotid plaque or ankle-arm indexes. They have additional value to each other and to classic risk factors and may reflect different processes.

Incidence, risk, and case fatality of first ever stroke in the elderly population. The Rotterdam Study

OBJECTIVE

To estimate the incidence, survival, and lifetime risk of stroke in the elderly population.

METHODS

The authors conducted a study in 7,721 participants from the population based Rotterdam Study who were free from stroke at baseline (1990-1993) and were followed up for stroke until 1 January 1999. Age and sex specific incidence, case fatality rates, and lifetime risks of stroke were calculated.

RESULTS

Mean follow up was 6.0 years and 432 strokes occurred. The incidence rate of stroke per 1,000 person years increased with age and ranged from 1.7 (95% CI 0.4 to 6.6) in men aged 55 to 59 years to 69.8 (95% CI 22.5 to 216.6) in men aged 95 years or over. Corresponding figures for women were 1.2 (95% CI 0.3 to 4.7) and 33.1 (95% CI 17.8 to 61.6). Men and women had similar absolute lifetime risks of stroke (21% for those aged 55 years). The survival after stroke did not differ according to sex.

CONCLUSIONS

Stroke incidence increases with age, also in the very old. Although the incidence rate is higher in men than in women over the entire age range, the lifetime risks were similar for both sexes.

Carotid plaques increase the risk of stroke and subtypes of cerebral infarction in asymptomatic elderly: the Rotterdam study

BACKGROUND

Few studies have quantified the relation between carotid plaques and stroke in asymptomatic patients, and limited data exist on the importance of location of plaques or the association with subtypes of cerebral infarction. We investigated the relationship between carotid plaques, measured at different locations, and risk of stroke and subtypes of cerebral infarction in a population-based study. Methods and Results- The study was based on the Rotterdam Study and included 4217 neurologically asymptomatic subjects aged 55 years or older. Presence of carotid plaques at 6 locations in the carotid arteries was assessed at baseline. Severity was categorized according to the number of affected sites. After a mean follow-up of 5.2 years, 160 strokes had occurred. Data were analyzed using Cox proportional hazards regression. Plaques increased the risk of stroke and cerebral infarction approximately 1.5-fold, irrespective of plaque location. Severe carotid plaques increased the risk of nonlacunar infarction in anterior (RR 3.2 [95% CI, 1.1 to 9.7]) but not in posterior circulation (RR 0.6 [95% CI, 0.1 to 4.9]). A >10-fold increased risk of lacunar infarction was found in subjects with severe plaques (RR 10.8 [95% CI, 1.7 to 69.7]). No clear difference in risk estimates was seen between ipsilateral and contralateral infarction.

CONCLUSIONS

Carotid plaques increase the risk of stroke and cerebral infarction, irrespective of their location. Plaques increase the risk of infarctions in the anterior but not in the posterior circulation. It is likely that carotid plaques in neurologically asymptomatic subjects are both markers of generalized atherosclerosis and sources of thromboemboli.

Is carotid intima-media thickness useful in cardiovascular disease risk assessment? The Rotterdam Study

BACKGROUND AND PURPOSE

We determined the contribution of common carotid intima-media thickness (IMT) in the prediction of future coronary heart disease and cerebrovascular disease when added to established risk factors.

METHODS

We used data from a nested case-control study comprising 374 subjects with either an incident stroke or a myocardial infarction and 1496 controls. All subjects were aged 55 years and older and participated in the Rotterdam Study. Mean follow-up was 4.2 years (range, 0.1 to 6.5 years). We evaluated which correlates of coronary heart disease and cerebrovascular disease contribute to the prediction of either a new incident myocardial infarction or a stroke. Logistic regression modeling and the area under the receiver operating characteristic curve (ROC area) were used to quantify the predictive value of the established risk factors and the added value of IMT.

RESULTS

The ROC area of a model with age and sex only was 0.65 (95% CI, 0.62 to 0.69). Independent risk factors were previous myocardial infarction and stroke, diabetes mellitus, smoking, systolic blood pressure, diastolic blood pressure, and total and HDL cholesterol levels. These risk factors increased the ROC area from 0.65 to 0.72 (95% CI, 0.69 to 0.75). This model correctly predicted 17% of all subjects with coronary heart disease and cerebrovascular disease. When common carotid IMT was added to the previous model, the ROC area increased to 0.75 (95% CI, 0.72 to 0.78). When only the IMT measurement was used, the ROC area was 0.71 (95% CI, 0.68 to 0.74), and 14% of all subjects were correctly predicted. There was no difference in ROC area when different measurement sites were used.

CONCLUSIONS

Adding IMT to a risk function for coronary heart disease and cerebrovascular disease does not result in a substantial increase in the predictive value when used as a screening tool.

Investigation of healthcare providers' patterns of referring breast cancer patients to Reach to Recovery

Providers who referred patients to Reach to Recovery (Reach), an American Cancer Society breast cancer support group, were compared with those who did not to evaluate whether providers who identified problems with the program were less likely to make referrals. Also considered were contact with a Reach volunteer, having a Reach program in the area, years since residency or medical training, perceived value of the Reach program, belief that one's peers refer patients to Reach, urban or rural location of practice, and size of practice. When other variables were considered, physicians who identified problems with Reach were no less likely to refer patients to the program than those who did not. The factors most associated with referral (P < .001) were "having a Reach program in the area" and "having had contact with a Reach volunteer." Implications of these findings and the experience of conducting the evaluation through the Collaborative Evaluations Fellows Project are discussed.

Is the prevalence of HIV-associated nephropathy decreasing?

Initial reports have suggested that approximately 10% of patients with HIV-infection develop HIV-associated nephropathy (HIVAN). It has also been predicted that by the end of the decade, HIVAN is likely to become a third leading cause of end-stage renal disease (ESRD) in African-Americans between the ages of 20-64 years. As the morbidity and mortality from HIV-infection has decreased in the last few years, it is possible that prevalence of HIVAN is also changing. We therefore screened HIV-1-infected patients followed in our hospital for HIVAN. A screening urinalysis was performed in 557 HIV-1-infected adult patients between March and May 1998. Of these, 252 were outpatients and 305 were Texas Department of Criminal Justice inmates (TDCJI). Demographic and laboratory data of these patients was obtained from the HIV patients' database. Fifty percent of the patients were African-American, 36.6% were Caucasian and 12. 7% were Hispanic. The mean age of patients was 37 +/- 8 years. Seventy-nine percent of the patients were males and a history of intravenous drug abuse (IVDA) was present in 28%. Twenty-three percent of the patients were concomitantly infected with hepatitis C virus, 4.1% were positive for hepatitis B surface antigen, and rapid plasma reagin test for syphilis was positive in 9.1%. In 38 patients who had more than 100 mg/dl (2+) proteins on screening urinalysis, total urinary proteins were quantitated by collecting 24 h urine specimens. Fifteen of these patients had urinary proteins more than 1.5 g/day (12 patients >3.5 g/24 h and 3 patients >1.5 g/24 h). A renal biopsy was done in 14 of these patients and clinical diagnosis of HIVAN was made in one patient who refused biopsy. Renal biopsies revealed HIVAN [9], diabetic nephropathy [2], membranoproliferative glomerulonephritis [2], Fibrillary glomerulonephritis [1]. All 10 patients (5 TDCJI and 5 outpatients) with HIVAN were African-American. Two of these 10 patients had a history of IVDA and another two were concomitantly infected with hepatitis C virus. The plasma viral load (Pvl) and total CD4 count was not different in patients with or without HIVAN [(Pvl log 10.05 +/- 1.39 vs. 9.9 +/- 2.18 copies/ml, p = 0.78) (CD4: 187 +/- 192 vs. 288 +/- 249 cells/microl, p = 1.17) mean +/- SD]. We conclude that in our HIV-infected population HIVAN exclusively affected African-Americans and the prevalence in them was 3.5%.

Financing long-term care in Canada

Financial policies relating to long-term care in Canada are changing rapidly in response to demands for health care reform. This chapter focuses on the financial structure of institutional care, primarily nursing homes, in the western provinces of Alberta and British Columbia. Community-based long-term care is discussed briefly.

Young children's understanding of thought bubbles and of thoughts

In a series of 4 studies, we explored preschoolers' understanding of thought bubbles. Very few 3-year-olds or 4-year-olds we tested knew what a thought-bubble depiction was without instruction. But, if simply told that the thought bubble "shows what someone is thinking," the vast majority of 3-year-olds and 4-year-olds easily understood the devices as depicting thoughts generally and individual thought contents specifically. In total, these children used thought-bubble depictions to ascertain the contents of characters' thoughts in a variety of situations; appropriately distinguished such depictions from mere associated actions or objects; described thought bubbles in the language of mental states; judged that persons' thoughts in these depictions were subjective in the sense of person-specific (and hence 2 people can have different thoughts about the same state of affairs); and judged that thought-bubble thoughts (a) were representational in the sense of depicting or showing some other state of affairs, (b) were mental and thus showed intangible, private, internal thoughts unlike real pictures or photographs, and (c) can be false, that is, can depict a person's misrepresentation of some state of affairs. We discuss the implications of these findings for young children's understanding of thoughts and thought bubbles, for their learning and comprehension of pictorial conventions, and for the use of thought bubbles to assess children's early understanding of mind.

Dynamic reliability models with conditional proportional hazards

A dynamic approach to the stochastic modelling of reliability systems is further explored. This modelling approach is particularly appropriate for load-sharing, software reliability, and multivariate failure-time models, where component failure characteristics are affected by their degree of use, amount of load, or extent of stresses experienced. This approach incorporates the intuitive notion that when a set of components in a coherent system fail at a certain time, there is a 'jump' from one structure function to another which governs the residual lifetimes of the remaining functioning components, and since the component lifetimes are intrinsically affected by the structure function which they constitute, then at such a failure time there should also be a jump in the stochastic structure of the lifetimes of the remaining components. For such dynamically-modelled systems, the stochastic characteristics of their jump times are studied. These properties of the jump times allow us to obtain the properties of the lifetime of the system. In particular, for a Markov dynamic model, specific expressions for the exact distribution function of the jump times are obtained for a general coherent system, a parallel system, and a series-parallel system. We derive a new family of distribution functions which describes the distributions of the jump times for a dynamically-modelled system.

Sensitivity of children's inflection to grammatical structure

What is the input to the mental system that computes inflected forms like walked, came, dogs, and men? Recent connectionist models feed a word's phonological features into a single network, allowing it to generalize both regular and irregular phonological patterns, like stop-stopped, step-stepped and fling-flung, cling-clung. But for adults, phonological input is insufficient: verbs derived from nouns like ring the city always have regular past tense forms (ringed), even if they are phonologically identical to irregular verbs (ring the bell). Similarly, nouns based on names, like two Mickey Mouses, and compounds based on possessing rather than being their root morpheme, such as two sabertooths, take regular plurals, even when they are homophonous with irregular nouns like mice and teeth. In four experiments, testing 70 three- to ten-year-old children, we found that children are sensitive to such nonphonological information: they were more likely to produce regular inflected forms for forms like to ring ('to put a ring on') and snaggletooth (a kind of animal doll with big teeth) than for their homophonous irregular counterparts, even when these counterparts were also extended in meaning. Children's inflectional systems thus seem to be like adults': irregular forms are tied to the lexicon but regular forms are computed by a default rule, and words are represented as morphological tree structures reflecting their derivation from basic word roots. Such structures, which determine how novel complex words are derived and interpreted, also govern whether words with irregular sound patterns will be regularized: a word can be irregular only if its structure contains an irregular root in 'head' position, allowing the lexically stored irregular information to percolate up to apply to the word as a whole. In all other cases, the inflected form is compouted by a default regular rule. This proposal fits the facts better than alternatives appealing to ambiguity reduction or semantic similarity to a word's central sense. The results, together with an analysis of adult speech to children, suggest that morphological structure and a distinction between mechanisms for regular and irregular inflection may be inherent to the design of children's language systems.

Affectedness and direct objects: the role of lexical semantics in the acquisition of verb argument structure

How do speakers predict the syntax of a verb from its meaning? Traditional theories posit that syntactically relevant information about semantic arguments consists of a list of thematic roles like "agent", "theme", and "goal", which are linked onto a hierarchy of grammatical positions like subject, object and oblique object. For verbs involving motion, the entity caused to move is defined as the "theme" or "patient" and linked to the object. However, this fails for many common verbs, as in fill water into the glass and cover a sheet onto the bed. In more recent theories verbs' meanings are multidimensional structures in which the motions, changes, and other events can be represented in separate but connected substructures; linking rules are sensitive to the position of an argument in a particular configuration. The verb's object would be linked not to the moving entity but to the argument specified as "affected" or caused to change as the main event in the verb's meaning. The change can either be one of location, resulting from motion in a particular manner, or of state, resulting from accommodating or reacting to a substance. For example, pour specifies how a substance moves (downward in a stream), so its substance argument is the object (pour the water/glass); fill specifies how a container changes (from not full to full), so its stationary container argument is the object (fill the glass/water). The newer theory was tested in three experiments. Children aged 3;4-9;4 and adults were taught made-up verbs, presented in a neutral syntactic context (this is mooping), referring to a transfer of items to a surface or container. Subjects were tested on their willingness to encode the moving items or the surface as the verb's object. For verbs where the items moved in a particular manner (e.g., zig-zagging), people were more likely to express the moving items as the object; for verbs where the surface changed state (e.g., shape, color, or fullness), people were more likely to express the surface as the object. This confirms that speakers are not confined to labeling moving entities as "themes" or "patients" and linking them to the grammatical object; when a stationary entity undergoes a state change as the result of a motion, it can be represented as the main affected argument and thereby linked to the grammatical object instead.

Managing noncompliance in a schizophrenic patient with chronic skin disorders

A schizophrenic-diagnosed woman with a long-term history of scratching and skin problems was referred for behavioral treatment because she was not responding well to medical care and was often described as noncompliant. The treatment of noncompliance consisted of four phases: (I) direct habit modification, (II) compliance training, (III) controlling anxiety precipitants and (IV) follow-up monitoring and evaluation. After several months of treatment, the maladaptive behaviors decreased and the skin condition improved. Follow-up at six month intervals for three years indicated no recurrence of skin problems.

CT scanography for limb length determination

The authors present an alternative to classic techniques used to measure limb length discrepancy radiographically. CT scanography seems to have advantages over currently-used Bell-Thompson roentgenography in that it uses less radiation and is of no increase in cost.

Acquired immunodeficiency with reversed T4/T8 ratios in infants born to promiscuous and drug-addicted mothers

A new syndrome of acquired immunodeficiency has been identified in seven children who were small for gestational age at birth and subsequently have exhibited failure to thrive, lymphadenopathy, parotitis, hepatosplenomegaly, interstitial pneumonia, and recurrent infections. All have a profound cell-mediated immunodeficiency with reversed T4/T8 ratios. Six are hypergammaglobulinemic and one has low IgG levels. The mothers of five of the seven children are sexually promiscuous and/or drug addicts. Three mothers have an immunodeficiency similar to that found in their infants. One of them died at age 33 years with a diagnosis of acquired immunodeficiency syndrome. In five of the children and in three of their mothers, there is evidence of a persistent Epstein-Barr virus (EBV) infection. We speculate that a perinatal or in utero transmission of EBV can induce an "infectious immunodeficiency." The clinical, histopathologic, and immunologic features resemble those described in adult homosexuals and drug addicts.

Tests for monotone mean residual life, using randomly censored data

At any age the mean residual life function gives the expected remaining life at that age. Reliabilists and biometricians have found it useful to categorize failure distributions by the monotonicity properties of the mean residual life function. Hollander and Proschan (1975, Biometrika 62, 585-593) have derived tests of the null hypothesis that the underlying failure distribution is exponential, versus the alternative that it has a monotone mean residual life function. These tests are based on a complete sample. Often, however, data are incomplete because of withdrawals from the study and because of survivors at the time the data are analyzed. In this paper we generalize the Hollander-Proschan tests to accommodate randomly censored data. The efficiency loss due to the presence of censoring is also investigated.

Multiple births in drug-addicted women

Two sets of twins and two sets of triplets were delivered in a group of 126 pregnant drug addicts. The over-all multiple-birth incidence of 1:32 is three times more prevalent than that found in the general population. Three of the four multiple births were dizygotic. The mothers with the dizygotic multiple births were on moderate to elevated levels of heroin or methadone at the time of conception. Mechanisms are presented to help explain why narcotics may cause supraovulation and multiple births.

Micro-scale blood lead determinations in screening: evaluation of factors affecting results

The Delves micro-scale technique for blood lead analysis is an accurate method for screening capillary blood specimens, obtained by fingerstick, for lead intoxication. Results are affected by the age of cup, loop, and hollow-cathode tube and by the spatial relationship between optical tube and cup. Because the glass in many commercially available capillary tubes (used in specimen collection) contains lead and cannot be decontaminated, a lead-free glass tube must be used. A solution of citric acid in ethanol (20 g/liter) effectively cleanses the puncture site. A double-blind study of 207 specimens gave a mean value of 276.6 plus or minus 105.8 mug/liter (1SD) for the micro-scale method vs. 273.2 plus or minus 99.0 for a macro-scale method. The mean coefficent of variation for the micro-scale method was 5.75 percent plus or minus 1.9 (SD). We conclude that values of 480 mug/liter or below are not "toxic" (i.e., are significantly less than 600 mug/liter, the value at which therapy is begun). The method is shown to be satisfactory as a screening procedure and for confirming lead analyses done by other methods.