Optical reflectance imaging reveals interlayer coupling in mechanically stacked MoS2 and WS2 bilayers

Optical reflectance imaging is a popular technique for characterizing 2D materials, thanks to its simplicity and speed of data acquisition. The use of this method for studying interlayer phenomena in stacked 2D layers has, however, remained limited. Here we demonstrate that optical imaging can reveal the nature of interlayer coupling in stacked MoS₂ and WS₂ bilayers through their observed reflectance contrast versus the substrate. Successful determination of interlayer coupling requires co-optimization of the illumination wavelength and the thickness of an underlying SiO₂ film. Our observations are supported by multilayer optical calculations together with an analysis of the effect of any interlayer gap. This approach promises quick characterization of constructed 2D material systems.

The effect of history of abnormal pap smear or preceding HPV infection on the humoral immune response to Quadrivalent Human Papilloma virus (qHPV) vaccine in women with systemic lupus erythematosus

OBJECTIVE

To determine if natural human papillomavirus (HPV) infection would induce an anamnestic response to quadrivalent (qHPV) vaccine in women with Systemic Lupus Erythematosus (SLE).

METHODS

Thirty four women (19-50 years) with mild to moderate and minimally active or inactive SLE received standard qHPV vaccine. Neutralizing antibody titers to HPV 6, 11, 16 and18 were evaluated pre- and post- vaccine using HPV competitive Luminex Immunoassay. For each HPV type, logistic regressions were performed to explore the relationship between a positive titer at baseline with their final geometric mean titer and with the rise in titer. Fisher's Exact Test was used to assess the association of at least one positive HPV antibody test at baseline and history of abnormal pap.

RESULTS

History of abnormal pap smear/cervical neoplasia occurred in 52.9%. Baseline anti HPV antibody titers: 21% = negative for all 4 HPV types, 79% = positive for ≥1 of the HPV types. Statistical analysis showed: those with a history of abnormal pap smear/cervical neoplasia were likely to have a positive anti-HPV antibody result pre-vaccine to ≥ 1 of the 4 types, p = 0.035 Fisher's Exact Test. In general, HPV exposed women showed higher post vaccine GMTs than HPV unexposed women with higher point estimates. However, when examining the rise in titers using logistic regression, there was no evidence of an anamnestic response.

CONCLUSION

Prior HPV infection and cervical neoplasia in SLE are linked with no anamnestic response to HPV vaccine. This supports not checking HPV-antibodies pre-vaccine. Women with SLE should be vaccinated for HPV.

A spongy nickel-organic CO2 reduction photocatalyst for nearly 100% selective CO production

Solar-driven photocatalytic conversion of CO₂ into fuels has attracted a lot of interest; however, developing active catalysts that can selectively convert CO₂ to fuels with desirable reaction products remains a grand challenge. For instance, complete suppression of the competing H₂ evolution during photocatalytic CO₂-to-CO conversion has not been achieved before. We design and synthesize a spongy nickel-organic heterogeneous photocatalyst via a photochemical route. The catalyst has a crystalline network architecture with a high concentration of defects. It is highly active in converting CO₂ to CO, with a production rate of ~1.6 × 10⁴ μmol hour^-1 g^-1. No measurable H₂ is generated during the reaction, leading to nearly 100% selective CO production over H₂ evolution. When the spongy Ni-organic catalyst is enriched with Rh or Ag nanocrystals, the controlled photocatalytic CO₂ reduction reactions generate formic acid and acetic acid. Achieving such a spongy nickel-organic photocatalyst is a critical step toward practical production of high-value multicarbon fuels using solar energy.

The safety and immunogenicity of Quadrivalent HPV (qHPV) vaccine in systemic lupus erythematosus

OBJECTIVE

This study evaluated the safety and immunogenicity of qHPV vaccine in SLE.

METHODS

Subjects: 34 women ages 19-50years (yrs.) with mild to moderate SLE & minimally active or inactive SLE received qHPV vaccine at the standard dosing schedule.

EXCLUSION CRITERIA

active SLE disease (SELENA-SLEDAI>2), history of severe SLE disease, deep venous thrombosis, on >400mg/day of hydroxychloroquine, on >15mg/day of prednisone, or active infections. Patients were monitored for adverse events (AE), SLE flare, generation of thrombogenic antibodies and thrombosis. Antibody (Ab) levels to HPV 6, 11, 16 & 18 were measured by HPV competitive Luminex Immunoassay and Geometric Mean Titers (GMTs) were calculated for each HPV type. Seroconversion was assessed for those seronegative at baseline.

RESULTS

The women in the study: African-American (79%), mean age=38.1years, mean age at diagnosis of SLE=28.6years, 35.3% had a history of smoking, 91% had 4 or more sexual partners, 50% had a history of sexually transmitted diseases, and 27.3% used condoms on a regular basis. Vaccine site reactions (VSRs) occurred in 62%, all mild. Ninety-seven percent experienced at least 1 non vaccine adverse event (nvAE) with a total of 493 nvAEs in 33 patients, of which 90% were mild and none were related to vaccine or SLE. There were 9 serious AEs, none were related to vaccine or SLE, all resolved. No patient experienced an SLE flare, thrombosis, or generation of thrombogenic antibodies. Seroconversion rate was 100% with mean GMTs comparable to Gardasil® package insert data.

CONCLUSION

In this SLE vaccine study, qHPV vaccine was generally safe, well tolerated, and highly immunogenic. This clinical trial is registered on Clinical Trials.gov under number, NCT01741012 and was conducted under the FDA IND BB14113.

Using database reports to reduce workplace violence: Perceptions of hospital stakeholders

BACKGROUND

Documented incidents of violence provide the foundation for any workplace violence prevention program. However, no published research to date has examined stakeholders' preferences for workplace violence data reports in healthcare settings. If relevant data are not readily available and effectively summarized and presented, the likelihood is low that they will be utilized by stakeholders in targeted efforts to reduce violence.

OBJECTIVE

To discover and describe hospital system stakeholders' perceptions of database-generated workplace violence data reports.

PARTICIPANTS

Eight hospital system stakeholders representing Human Resources, Security, Occupational Health Services, Quality and Safety, and Labor in a large, metropolitan hospital system.

METHODS

The hospital system utilizes a central database for reporting adverse workplace events, including incidents of violence. A focus group was conducted to identify stakeholders' preferences and specifications for standardized, computerized reports of workplace violence data to be generated by the central database. The discussion was audio-taped, transcribed verbatim, processed as text, and analyzed using stepwise content analysis.

RESULTS

Five distinct themes emerged from participant responses: Concerns, Etiology, Customization, Use, and Outcomes. In general, stakeholders wanted data reports to provide ``the big picture,'' i.e., rates of occurrence; reasons for and details regarding incident occurrence; consequences for the individual employee and/or the workplace; and organizational efforts that were employed to deal with the incident.

CONCLUSIONS

Exploring stakeholder views regarding workplace violence summary reports provided concrete information on the preferred content, format, and use of workplace violence data. Participants desired both epidemiological and incident-specific data in order to better understand and work to prevent the workplace violence occurring in their hospital system.

Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer

PURPOSE

Overtreatment of screen-detected localized prostate cancer (LPC) is an important public health concern, since the survival benefit of aggressive treatment (surgery or radiation) has not been well established. We investigated the survival expectations of patients who had LPC with and without their chosen treatment.

METHODS

A population-based sample of 260 men (132 black, 128 white) 75 years old or younger with newly diagnosed LPC completed a self-administered survey. How long the patients expected to live with their chosen treatment, how long they would expect to live with no treatment, and factors associated with the difference in perceived life expectancy were assessed using multivariable analysis.

RESULTS

Without any treatment, 33% of patients expected that they would live less than 5 years, 41% 5 to 10 years, 21% 10 to 20 years, and 5% more than 20 years. With their chosen treatment, 3% of patients expected to live less than 5 years, 9% 5 to 10 years, 33% 10 to 20 years, and 55% more than 20 years. Treatment chosen, age, general health perception, and perceived cancer seriousness predicted the differences in perceived life expectancy, while race and actual tumor risk did not. After adjustment for other covariates, men who choose surgery or radiation expected greater gain in survival than men who chose watchful waiting or active surveillance.

CONCLUSIONS

Most patients with LPC underestimated their life expectancy without treatment and overestimated the gain in life expectancy with surgery or radiation. These unrealistic expectations may compromise patients' ability to make informed treatment decisions and may contribute to overtreatment of LPC. Primary care physicians, when included in the decision process, should focus on helping patients develop realistic expectations and choices that support their treatment goals.

Patient education and follow-up as an intervention for hypertensive patients discharged from an emergency department: a randomized control trial study protocol

Background

Persistently elevated blood pressure (BP) is a leading risk factor for cardiovascular disease development, making effective hypertension management an issue of considerable public health importance. Hypertension is particularly prominent among African Americans, who have higher disease prevalence and consistently lower BP control than Whites and Hispanics. Emergency departments (ED) have limited resources for chronic disease management, especially for under-served patients dependent upon the ED for primary care, and are not equipped to conduct follow-up. Kiosk-based patient education has been found to be effective in primary care settings, but little research has been done on the effectiveness of interactive patient education modules as ED enhanced discharge for an under-served urban minority population.

Methods/Design

Achieving Blood Pressure Control Through Enhanced Discharge (AchieveBP) is a behavioral RCT patient education intervention for patients with a history of hypertension who have uncontrolled BP at ED discharge. The project will recruit up to 200 eligible participants at the ED, primarily African-American, who will be asked to return to a nearby clinical research center for seven, thirty and ninety day visits, with a 180 day follow-up. Consenting participants will be randomized to either an attention-control or kiosk-based interactive patient education intervention. To control for potential medication effects, all participants will be prescribed similar, evidenced-based anti-hypertensive regimens and have their prescription filled onsite at the ED and during visits to the clinic. The primary target endpoint will be success in achieving BP control assessed at 180 days follow-up post-ED discharge. The secondary aim will be to assess the relationship between patient activation and self-care management.

Discussion

The AchieveBP trial will determine whether using interactive patient education delivered through health information technology as ED enhanced discharge with subsequent education sessions at a clinic is an effective strategy for achieving short-term patient management of BP. The project is innovative in that it uses the ED as an initial point of service for kiosk-based health education designed to increase BP self-management. It is anticipated findings from this translational research could also be used as a resource for patient education and follow-up with hypertensive patients in primary care settings.

Trial registration

ClinicalTrials.gov Registration Number: NCT02069015. Registered February 19, 2014.

Worker-to-Worker Violence in Hospitals: Perpetrator Characteristics and Common Dyads

Worker-to-worker (Type III) violence is prevalent in health care settings and has potential adverse consequences for employees and organizations. Little research has examined perpetrator characteristics of this type of violence. The current study is a descriptive examination of the common demographic and work-related characteristics of perpetrators of Type III workplace violence among hospital workers. Analysis was based on documented incidents of Type III violence reported within a large hospital system from 2010 to 2012. Nurses were involved as either the perpetrator or target in the five most common perpetrator-target dyads. Incidence rate ratios revealed that patient care associates and nurses were significantly more likely to be perpetrators than other job titles. By examining characteristics of perpetrators and common worker dyads involved in Type III workplace violence, hospital stakeholders and unit supervisors have a starting point to develop strategies for reducing conflict between workers.

Letrozole, Gonadotropin, or Clomiphene for Unexplained Infertility

BACKGROUND

The standard therapy for women with unexplained infertility is gonadotropin or clomiphene citrate. Ovarian stimulation with letrozole has been proposed to reduce multiple gestations while maintaining live birth rates.

METHODS

We enrolled couples with unexplained infertility in a multicenter, randomized trial. Ovulatory women 18 to 40 years of age with at least one patent fallopian tube were randomly assigned to ovarian stimulation (up to four cycles) with gonadotropin (301 women), clomiphene (300), or letrozole (299). The primary outcome was the rate of multiple gestations among women with clinical pregnancies.

RESULTS

After treatment with gonadotropin, clomiphene, or letrozole, clinical pregnancies occurred in 35.5%, 28.3%, and 22.4% of cycles, and live birth in 32.2%, 23.3%, and 18.7%, respectively; pregnancy rates with letrozole were significantly lower than the rates with standard therapy (gonadotropin or clomiphene) (P=0.003) or gonadotropin alone (P<0.001) but not with clomiphene alone (P=0.10). Among ongoing pregnancies with fetal heart activity, the multiple gestation rate with letrozole (9 of 67 pregnancies, 13%) did not differ significantly from the rate with gonadotropin or clomiphene (42 of 192, 22%; P=0.15) or clomiphene alone (8 of 85, 9%; P=0.44) but was lower than the rate with gonadotropin alone (34 of 107, 32%; P=0.006). All multiple gestations in the clomiphene and letrozole groups were twins, whereas gonadotropin treatment resulted in 24 twin and 10 triplet gestations. There were no significant differences among groups in the frequencies of congenital anomalies or major fetal and neonatal complications.

CONCLUSIONS

In women with unexplained infertility, ovarian stimulation with letrozole resulted in a significantly lower frequency of multiple gestation but also a lower frequency of live birth, as compared with gonadotropin but not as compared with clomiphene. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01044862.).

Catalysts of worker-to-worker violence and incivility in hospitals

AIMS AND OBJECTIVES

To identify common catalysts of worker-to-worker violence and incivility in hospital settings.

BACKGROUND

Worker-to-worker violence and incivility are prevalent forms of mistreatment in healthcare workplaces. These are forms of counterproductive work behaviour that can lead to negative outcomes for employees, patients and the organisation overall. Identifying the factors that lead to co-worker mistreatment is a critical first step in the development of interventions targeting these behaviours.

DESIGN

Retrospective descriptive study.

METHODS

Qualitative content analysis was conducted on the total sample (n = 141) of employee incident reports of worker-to-worker violence and incivility that were documented in 2011 at a large American hospital system.

RESULTS

More than 50% of the incidents involved nurses, and the majority of incidents did not involve physical violence. Two primary themes emerged from the analysis: Work Behaviour and Work Organisation. Incidents in the Work Behaviour category were often sparked by unprofessional behaviour, disagreement over responsibilities for work tasks or methods of patient care, and dissatisfaction with a co-worker's performance. Incidents in the Work Organisation category involved conflicts or aggression arising from failure to following protocol, patient assignments, limited resources and high workload.

CONCLUSION

Incidents of worker-to-worker violence and incivility stemmed from dissatisfaction with employee behaviour or from organisational practices or work constraints. These incident descriptions reflect worker dissatisfaction and frustration, resulting from poor communication and collaboration between employees, all of which threaten work productivity.

RELEVANCE TO CLINICAL PRACTICE

Violence and incivility between hospital employees can contribute to turnover of top performers, hinder effective teamwork and jeopardise the quality of patient care. Identification of common catalysts for worker-to-worker violence and incivility informs the development of mistreatment prevention programmes that can be used to educate hospital staff.

Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents

This study examined differences between self-report and actual documentation of workplace violence (WPV) incidents in a cohort of health care workers. The study was conducted in an American hospital system with a central electronic database for reporting WPV events. In 2013, employees (n = 2010) were surveyed by mail about their experience of WPV in the previous year. Survey responses were compared with actual events entered into the electronic system. Of questionnaire respondents who self-reported a violent event in the past year, 88% had not documented an incident in the electronic system. However, more than 45% had reported violence informally, for example, to their supervisors. The researchers found that if employees were injured or lost time from work, they were more likely to formally report a violent event. Understanding the magnitude of underreporting and characteristics of health care workers who are less likely to report may assist hospitals in determining where to focus violence education and prevention efforts.

Alcohol, tobacco, cocaine, and marijuana use: relative contributions to preterm delivery and fetal growth restriction

BACKGROUND

Pregnancy substance use is linked to low birth weight. However, less is known about relative contributions of various substances and whether effects are due to decreased gestational duration, restriction of fetal growth, or both. The study goal was to use causal modeling to evaluate the individual impact of alcohol, tobacco, cocaine, and marijuana on gestational duration and fetal growth.

METHODS

Participants were 3164 urban black women recruited at entry to prenatal care and followed to delivery, with all gestational dating ultrasound supported. Pregnancy substance use was assessed via self-report (alcohol, tobacco, cocaine, and marijuana).

RESULTS

Alcohol, cigarette, and cocaine use were all individually and negatively related to gestational age at delivery. However, only alcohol, cigarette, and marijuana use predicted fetal growth, with effects for alcohol and cigarette greater and more discrepant for older women. Overall, heavy cigarette smoking had the greatest individual impact on birth weight (up to 431 g). Heavy levels of use of all 4 substances by older women decreased birth weight by 26% (806 g).

CONCLUSIONS

For perhaps the first time, reduced birth weight is apportioned both by type of substance and mechanism of effect. The use of alcohol and/or cigarettes was clearly more harmful to fetal growth than cocaine use. Findings demonstrate the need for continued emphasis on intervention efforts to address legal and illicit pregnancy substance use.

Assessment of multiple intrauterine gestations from ovarian stimulation (AMIGOS) trial: baseline characteristics

OBJECTIVE

To identify baseline characteristics of women with unexplained infertility to determine whether treatment with an aromatase inhibitor will result in a lower rate of multiple gestations than current standard ovulation induction medications.

DESIGN

Randomized, prospective clinical trial.

SETTING

Multicenter university-based clinical practices.

PATIENT(S)

A total of 900 couples with unexplained infertility.

INTERVENTION(S)

Collection of baseline demographics, blood samples, and ultrasonographic assessments.

MAIN OUTCOME MEASURE(S)

Demographic, laboratory, imaging, and survey characteristics.

RESULT(S)

Demographic characteristics of women receiving clomiphene citrate (CC), letrozole, or gonadotropins for ovarian stimulation were very consistent. Their mean age was 32.2 ± 4.4 years and infertility duration was 34.7 ± 25.7 months, with 59% primary infertility. More than one-third of the women were current or past smokers. The mean body mass index (BMI) was 27 and mean antimüllerian hormone level was 2.6; only 11 women (1.3%) had antral follicle counts of <5. Similar observations were identified for hormonal profiles, ultrasound characterization of the ovaries, semen parameters, and quality of life assessments in both male and female partners.

CONCLUSION(S)

The cause of infertility in the couples recruited to this treatment trial is elusive, as the women were regularly ovulating and had evidence of good ovarian reserve both by basal FSH, antimüllerian hormone levels, and antral follicle counts; the male partners had normal semen parameters. The three treatment groups have common baseline characteristics, thereby providing comparable patient populations for testing the hypothesis that use of letrozole for ovarian stimulation can reduce the rates of multiples from that observed with gonadotropin and CC treatment.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 01044862.

Application and implementation of the hazard risk matrix to identify hospital workplaces at risk for violence

BACKGROUND

A key barrier to preventing workplace violence injury is the lack of methodology for prioritizing the allocation of limited prevention resources. The hazard risk matrix was used to categorize the probability and severity of violence in hospitals to enable prioritization of units for safety intervention.

METHODS

Probability of violence was based on violence incidence rates; severity was based on lost time management claims for violence-related injuries. Cells of the hazard risk matrix were populated with hospital units categorized as low, medium, or high probability and severity. Hospital stakeholders reviewed the matrix after categorization to address the possible confounding of underreporting.

RESULTS

Forty-one hospital units were categorized as medium or high on both severity and probability and were prioritized for forthcoming interventions. Probability and severity were highest in psychiatric care units.

CONCLUSIONS

This risk analysis tool may be useful for hospital administrators in prioritizing units for violence injury prevention efforts.

Understanding patient-to-worker violence in hospitals: a qualitative analysis of documented incident reports

AIM

To explore catalysts to, and circumstances surrounding, patient-to-worker violent incidents recorded by employees in a hospital system database.

BACKGROUND

Violence by patients towards healthcare workers (Type II workplace violence) is a significant occupational hazard in hospitals worldwide. Studies to date have failed to investigate its root causes due to a lack of empirical research based on documented episodes of patient violence.

DESIGN

Qualitative content analysis.

METHODS

Content analysis was conducted on the total sample of 214 Type II incidents documented in 2011 by employees of an American hospital system with a centralized reporting system.

FINDINGS

The majority of incidents were reported by nurses (39·8%), security staff (15·9%) and nurse assistants (14·4%). Three distinct themes were identified from the analysis: Patient Behaviour, Patient Care and Situational Events. Specific causes of violence related to Patient Behaviour were cognitive impairment and demanding to leave. Catalysts related to patient care were the use of needles, patient pain/discomfort and physical transfers of patients. Situational factors included the use/presence of restraints; transitions in the care process; intervening to protect patients and/or staff; and redirecting patients.

CONCLUSIONS

Identifying catalysts and situations involved in patient violence in hospitals informs administrators about potential targets for intervention. Hospital staff can be trained to recognize these specific risk factors for patient violence and can be educated in how to best mitigate or prevent the most common forms of violent behaviour. A social-ecological model can be adapted to the hospital setting as a framework for prevention of patient violence towards staff.

Worker-on-worker violence among hospital employees

Violence toward hospital workers is an internationally recognized occupational hazard. While patients are frequently perpetrators of physical violence, other employees are often responsible for acts of nonphysical violence. However, few hospitals have systems for documenting and monitoring worker-on-worker violence. This study encompassed all incidents of worker-on-worker violence recorded by employees in a hospital system database over a six-year period. Incidence rates per 100 full-time equivalents (FTEs) and rate ratios (RR) were calculated by year, hospital, and job category. The majority (87%) of worker-on-worker incidents involved nonphysical conflict. The overall incidence rate was 1.65/100 FTEs, ranging among the six hospitals from 0.54 to 3.42/100 FTEs. Based on multivariate analysis, no single professional group was at increased risk for worker-on-worker violence. Co-worker violence threatens the well-being of hospital employees and should be regularly tracked with other forms of workplace violence so that suitable intervention programs can be implemented and assessed.

Development and application of a population-based system for workplace violence surveillance in hospitals

BACKGROUND

A unique and comprehensive reporting and population-based violence surveillance system in a multi-site hospital system is presented.

METHODS

Incidence rates and rate ratios (RR) were calculated by year, hospital, violence type, and job category in six hospitals, 2003-2008.

RESULTS

Incidence rates per hospital for the 6-year period ranged from a low of 1.52 to a high of 10.89 incidents/100 full-time equivalents (FTEs), with the highest risk at a hospital with an outpatient mental health facility (RR = 7.16, 95%CI = 5.17-10.26). Rates for worker-on-worker violence exceeded rates for patient-to-worker violence from 2004 to 2008. Mental health technicians (RR = 13.82, 95%CI =  1.13-17.29) and security personnel (RR = 2.25, CI = 1.68-3.00) were at greatest risk for violence.

CONCLUSIONS

This surveillance system provides ongoing information on professional groups and hospital departments at risk and trends in violence reporting over time. It can be used to determine where appropriate violence prevention efforts are most needed, and to evaluate violence interventions.

Estimating rates of multiple gestation pregnancies: sample size calculation from the assessment of multiple intrauterine gestations from ovarian stimulation (AMIGOS) trial

Infertility afflicts 15% of couples who wish to conceive. Despite intensive evaluation of both male and female partners, the etiology may remain unknown leading to a diagnosis of unexplained infertility. For such couples, treatment often entails ovulation induction (OI) with fertility medications coupled with intrauterine insemination. Complications of this therapy include ovarian hyperstimulation syndrome and creation of multiple gestation pregnancies, which can be complicated by preterm labor and delivery, and the associated neonatal morbidity and expense of care for preterm infants. The Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) study is designed to assess whether OI in couples with unexplained infertility with an aromatase inhibitor produces mono-follicular development in most cycles, thereby reducing multiple gestations while maintaining a comparable pregnancy success rate to that achieved by OI with either gonadotropins or clomiphene citrate. These results will provide future guidance of therapy for couples with unexplained infertility, and if comparable pregnancy rates are achieved with a substantial reduction in multiple gestations, the public health benefit will be considerable.

Pre- and post-displacement stressors and time of migration as related to self-rated health among Iraqi immigrants and refugees in Southeast Michigan

The objective of this study was to determine whether perceived health status of Iraqi immigrants and refugees residing in the United States was related to pre-migration environmental stress, current unemployment, and if they had emigrated before or after the 1991 Gulf War. A random sample of Iraqis residing in Southeast Michigan, US, was interviewed using an Arab language structured survey. The main outcome measure was self-rated health (SRH). Major predictors included socioeconomics, employment status, pre-migration environmental stress, and health disorders. Path analysis was used to look at mediating effects between predictors and SRH. We found that SRH was significantly worse among participants that had left Iraq after the 1991 Gulf War. Unemployment and environmental stress exposure were inversely related to SRH. There was a direct path between Gulf War exposure and poor health. In addition, there were indirect paths mediated through psychosomatic and psychiatric disorders to SRH. Another path went from Gulf War exposure, via environmental stress and somatic health to poor health. Unemployment had a direct path, as well as indirect paths mediated through psychiatric and psychosomatic disorders, to poor self-rated health. In conclusion, these results suggest that pre- as well as post-migration factors, and period of migration, affect health.

Just say "I don't": lack of concordance between teen report and biological measures of drug use

BACKGROUND

Prevalence estimates of illicit drug use by teens are typically generated from confidential or anonymous self-report. While data comparing teen self-report with biological measures are limited, adult studies identify varying degrees of under-reporting.

METHODS

Hair analyses for cocaine, opiates and marijuana were compared to confidential teen self- and parent-reported teen drug use in a longitudinal cohort of >400 high-risk urban teens and parents.

RESULTS

Both teens and parents substantially underreported recent teen cocaine and opiate use. However, compared with parents, teens were more likely to deny biomarker-verified cocaine use. Teen specimens (hair) were 52 times more likely to identify cocaine use compared with self-report. Parent hair analyses for cocaine and opiate use were 6.5 times and 5.5 times, respectively, more likely to indicate drug use than were parental self-report. The lack of concordance between self-report and bioassay occurred despite participant's knowledge that a "certificate of confidentiality" protected both teen and adult participants, and that the biological specimens would be tested for drugs.

CONCLUSIONS

These findings confirm prior reports of adult under-reporting of their own drug use while extending our understanding of teen's self-admitted drug use. The lack of concordance between teen self- or parent-reported teen drug use and biomarkers confirm our concerns that both teen- and parent-reported teen drug use is limited, at least for youth in high-risk urban settings. Methods of ascertainment other than self- or parent-report must be considered when health care providers, researchers and public health agencies attempt to estimate teen drug-use prevalence.

The impact of maternal age on the effects of prenatal alcohol exposure on attention

BACKGROUND

Prenatal exposure to alcohol has a variety of morphologic and neurobehavioral consequences, yet more than 10% of women continue to drink during pregnancy, placing their offspring at risk for fetal alcohol spectrum disorders (FASD). Identification of at-risk pregnancies has been difficult, in part, because the presence and severity of FASD are influenced by factors beyond the pattern of alcohol consumption. Establishing maternal characteristics, such as maternal age, that increase the risk of FASD is critical for targeted pregnancy intervention.

METHODS

We examined the moderating effect of maternal age on measures of attention in 462 children from a longitudinal cohort born to women with known alcohol consumption levels (absolute ounces of alcohol per day at conception) who were recruited during pregnancy. Analyses examined the impact of binge drinking, as average ounces of absolute alcohol per drinking day. Smoking and use of cocaine, marijuana, and opiates were also assessed. At 7 years of age, the children completed the Continuous Performance Test, and their teachers completed the Achenbach Teacher Report Form.

RESULTS

After controlling for covariates, stepwise multiple regression analyses revealed a negative relation between levels of prenatal binge drinking and several measures of attention. The interaction between alcohol consumption and maternal age was also significant, indicating that the impact of maternal binge drinking during pregnancy on attention was greater among children born to older drinking mothers.

CONCLUSION

These findings are consistent with previous findings that children born to older alcohol-using women have more deleterious effects of prenatal alcohol exposure on other neurobehavioral outcomes.

Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis

OBJECTIVES

Compare the diagnostic performance of stress echocardiography (SE) and myocardial perfusion imaging (MPI) for the diagnosis of left main disease (LM) and triple vessel disease (TVD).

BACKGROUND

Limited comparative data on MPI and SE for the detection of LM and TVD (high-risk coronary artery disease) exist in the literature.

METHODS

Quantitative meta-analysis was performed using studies identified by systematic electronic literature search. Articles were included if they reported data on exercise, dobutamine SE or exercise, adenosine, dipyridamole, thallium201, technetium 99m sestamibi MPI and used coronary angiography as the reference test. Summary receiver-operating characteristic (SROC) curves were constructed for each imaging modality. Additionally, pooled sensitivity, specificity and likelihood ratios were calculated per modality. Meta-regression was performed to adjust for patient and study characteristics.

RESULTS

Thirty-two studies met inclusion criteria; 23 (MPI-15; SE-14; Common studies-6) provided sufficient data for analysis. In a SROC model comparing the two imaging modalities, SE was associated with higher area under curve (0.82 (0.03) vs 0.73 (0.02), p=0.01) and index Q* value (0.75 (0.02) vs 0.67 (0.02), p=0.01). Using pooled summary point estimates, SE had higher pooled sensitivity (94% vs 75%, p<0.001) and lower negative likelihood ratio (0.21 vs 0.47, p<0.001) compared to MPI. No evidence of a difference in the pooled specificity (40% vs 48%, p=0.16) and positive likelihood ratio (1.52 vs 1.58, p=0.36) was seen between the two stress modalities. Pooled diagnostic OR on meta-regression (9.78 vs 4.06, p=0.02) remained significantly higher for SE compared to MPI for identification of LM and TVD even after adjustment for study characteristics.

CONCLUSIONS

Since LM alone or in combination with TVD are categorised as representing potentially life-threatening variants of CAD, a screening test with high sensitivity, low negative likelihood ratio or higher discriminatory capacity would be desirable for risk stratification. In the absence of a direct head-to-head comparison of the diagnostic accuracies of SE and MPI, our findings indicate that SE appears to be the preferred screening modality for high-risk coronary artery disease.

Prenatal and postnatal cocaine exposure predict teen cocaine use

Preclinical studies have identified alterations in cocaine and alcohol self-administration and behavioral responses to pharmacological challenges in adolescent offspring following prenatal exposure. To date, no published human studies have evaluated the relation between prenatal cocaine exposure and postnatal adolescent cocaine use. Human studies of prenatal cocaine-exposed children have also noted an increase in behaviors previously associated with substance use/abuse in teens and young adults, specifically childhood and teen externalizing behaviors, impulsivity, and attention problems. Despite these findings, human research has not addressed prior prenatal exposure as a potential predictor of teen drug use behavior. The purpose of this study was to evaluate the relations between prenatal cocaine exposure and teen cocaine use in a prospective longitudinal cohort (n=316) that permitted extensive control for child, parent and community risk factors. Logistic regression analyses and Structural Equation Modeling revealed that both prenatal exposure and postnatal parent/caregiver cocaine use were uniquely related to teen use of cocaine at age 14 years. Teen cocaine use was also directly predicted by teen community violence exposure and caregiver negativity, and was indirectly related to teen community drug exposure. These data provide further evidence of the importance of prenatal exposure, family and community factors in the intergenerational transmission of teen/young adult substance abuse/use.

Is patient involvement during hospitalization for acute myocardial infarction associated with post-discharge treatment outcome? An exploratory study

OBJECTIVE

To investigate whether patient involvement during hospitalization for acute myocardial infarction (MI) was associated with health and behavioural outcomes 6-10 weeks after hospital discharge.

BACKGROUND

Patient involvement has been associated with improved health outcomes in chronic disease, but less research has focused on the effects of patient involvement in acute conditions, such as MI.

DESIGN

Self-administered questionnaire study. Questionnaire results were run against medical outcome data in a national database of cardiac patients.

SETTING AND PARTICIPANTS

Cardiac patients (n = 591) on their first follow-up visit after hospitalization for MI at 11 Swedish hospitals.

MAIN OUTCOME MEASURES

Patient ratings of three questionnaire scales related to involvement; cardiovascular symptoms, medication compliance, participation in cardiac rehabilitation, and achievement of secondary preventive goals.

RESULTS

More positive patient ratings of involvement were significantly associated with fewer cardiovascular symptoms 6-10 weeks after hospital discharge. In contrast, patients who attended cardiac rehabilitation and achieved the goals for smoking cessation and systolic blood pressure were significantly less satisfied with their involvement. No association was found between involvement ratings and medication compliance.

CONCLUSION

This study represents a first attempt to examine associations between patient involvement in the acute phase of illness and short-term health outcomes. Some significant associations between involvement and health and behavioural outcomes after acute MI were found. However, higher involvement ratings were not consistently associated with more desirable outcomes, and involvement during hospitalization was not associated with MI patient health and behaviour 6-10 weeks after hospital discharge to the extent hypothesized.

Alterations in frontal lobe tracts and corpus callosum in young children with autism spectrum disorder

Major frontal lobe tracts and corpus callosum (CC) were investigated in 32 children with autism spectrum disorder (ASD, mean age: 5 years), 12 nonautistic developmentally impaired children (DI, mean age: 4.6 years), and 16 typically developing children (TD, mean age: 5.5 years) using diffusion tensor imaging tractography and tract-based spatial statistics. Various diffusion and geometric properties were calculated for uncinate fasciculus (UF), inferior fronto-occipital fasciculus (IFO), arcuate fasciculus (AF), cingulum (Cg), CC, and corticospinal tract. Fractional anisotropy was lower in the right UF, right Cg and CC in ASD and DI children; in right AF in ASD children; and in bilateral IFO in DI children, compared with TD children. Apparent diffusion coefficient was increased in right AF in both ASD and DI children. The ASD group showed shorter length of left UF and increased length, volume, and density of right UF; increased length and density of CC; and higher density of left Cg, compared with the TD group. Compared with DI group, ASD group had increased length, volume, and density of right UF; higher volume of left UF; and increased length of right AF and CC. Volume of bilateral UF and right AF and fiber density of left UF were positively associated with autistic features.

Changes in weather and the effects on pediatric asthma exacerbations

BACKGROUND

Pediatric asthma exacerbations may correlate with changes in weather, yet this relationship is not well defined.

OBJECTIVE

To determine the effects of fluctuations in climatic factors (temperature, humidity, and barometric pressure) on pediatric asthma exacerbations.

METHODS

A retrospective study was performed at 1 large urban hospital during a 2-year period (January 1, 2004, to December 31, 2005). Children presenting to the emergency department (ED) for an asthma exacerbation were included. Data on climactic factors, pollutants, and aeroallergens were collected daily. The relationship of daily (intraday) or between-day (interday) changes in climactic factors and asthma ED visits was evaluated using time series analysis, controlling for seasonality, air pollution, and aeroallergen exposure. The effects of climactic factors were evaluated on the day of admission (T=0) and up to 5 days before admission (T-5 through T-1).

RESULTS

There were 25,401 asthma ED visits. A 10% intraday increase in humidity on day T-1 or day T-2 was associated with approximately 1 additional ED visit for asthma (P < .001 and P = .01, respectively). Interday changes in humidity from day T - 3 to T-2 were also associated with more ED visits (P < .001). Interday changes in temperature from T-1 to T = 0 increased ED visits, with a 10 degrees F increase being associated with 1.8 additional visits (P = .006). No association was found with changes in barometric pressure.

CONCLUSION

Fluctuations in humidity and temperature, but not barometric pressure, appear to influence ED visits for pediatric asthma. The additional ED visits occur 1 to 2 days after the fluctuation.

Thrombophilic patterns of coagulation factors in lupus

Our aim was to better define the coagulation abnormalities in patients with systemic lupus erythematosus who had thrombosis or high-risk clinical settings for thrombosis. Clinical and laboratory data of 111 patients with lupus referred for coagulation assessment because of thrombosis, pregnancy loss or high-risk clinical settings for thrombosis were reviewed retrospectively. Increased activity of procoagulant factors and decreased activity of anti-coagulant factors were observed well above the expected 5% prevalence. All comparisons were significant at the P < 0.001 level. Anticardiolipin antibodies were present in 70.5% of patients tested (55/78) in this high-risk group, but usually in low titres. Platelet hyperfunction was detected in the majority of patients tested (85.7%, 78/91). Hypercoagulability in lupus is complex and is better defined by assessing multiple haemostatic factors in addition to platelet function. Platelet hyperfunction contributes significantly to thrombophilia in lupus and this is the key finding of our study.

Exhaled nitric oxide measurements in hospitalized children with asthma

BACKGROUND

The reproducibility of exhaled nitric oxide (FE(NO)) measurements performed in pediatric hospitalized asthmatics has not been previously evaluated.

OBJECTIVE

To evaluate the reproducibility of FE(NO) measurements in the hospital; to look for differences between those who were and were not able to perform FE(NO) measurements; and to assess any factors correlated with FE(NO) measurements.

METHODS

89 hospitalized pediatric asthmatics performed FE(NO), FEV1, and peak expiratory flow rate (PEFR) maneuvers in triplicate at the time of discharge. Reproducibility was assessed using the intraclass correlation coefficient (ICC) and coefficient of variation (CV). Demographic and measured variables were compared between those who were and were not able to perform FE(NO) measurements. Correlation of FE(NO) with other variables was investigated.

RESULTS

FE(NO) measurements showed clinically acceptable ICC and CV values (0.973 and 5.59%, respectively). These values were superior to the values obtained for FEV1 and PEFR. Subjects who successfully performed the FE(NO) measurements were older, had higher PEFR readings, and had a lower asthma dyspnea score. No correlation was found between FE(NO) and traditional asthma factors, though multiple factors did trend towards significance.

CONCLUSION

FE(NO) measurements can be obtained in hospitalized pediatric patients with good reproducibility. While the majority of children will be able to provide such readings, those who are younger and with a more severe exacerbation may be unsuccessful in doing so. Further research is needed to determine how best to incorporate FE(NO) values into the hospital setting.

Evaluation of exhaled nitric oxide measurements in the emergency department for patients with acute asthma

BACKGROUND

Fraction of exhaled nitric oxide (FE(NO)) measurements performed on patients with acute asthma in the emergency department (ED) have previously shown poor reproducibility.

OBJECTIVES

To evaluate the reproducibility of FE(NO) measurements in the ED using a new monitoring device, to evaluate any factors that may correlate with FE(NO) measurements, and to investigate if FE(NO) levels predict the need for admission to the hospital.

METHODS

Thirty-five adult patients with asthma seen in the ED performed FE(NO), forced expiratory volume in 1 second, and peak expiratory flow rate maneuvers in triplicate. Reproducibility was evaluated using the intraclass correlation coefficient and the coefficient of variation. Associations between FE(NO), demographic, and traditional asthma measurements were investigated. The FE(NO) levels between patients admitted for further care and those discharged home were compared.

RESULTS

The FE(NO) measurements showed acceptable intraclass correlation coefficient and coefficient of variation values (0.98 and 9.42%, respectively) for reproducibility. These values were superior to the values obtained for forced expiratory volume in 1 second and peak expiratory flow rate. No correlation was found between FE(NO) and traditional asthma factors, although length of the asthma attack trended toward statistical significance (P = .08). The FE(NO) levels did not differ between those admitted and those discharged home (P = .53).

CONCLUSIONS

Fraction of exhaled nitric oxide measurements can be obtained in the ED setting with good reproducibility. These measurements may provide useful information not obtainable by other means. Further research is needed to determine how best to incorporate FE(NO) values into the ED setting.

Exhaled nitric oxide levels during treatment in patients hospitalized with asthma

The time required for fractional excretion of nitric oxide (FE(NO)) measurements to acutely change after systemic corticosteroids is unknown, limiting the usefulness of this biomarker in hospital treatment and discharge decisions. The purpose of this study was to follow FE(NO) measurements of hospitalized adult patients with asthma receiving therapy and to correlate FE(NO) with forced expiratory volume in 1 second percent predicted (FEV(1)%). Ten acute asthmatic patients who required hospitalization were recruited and treated with standard therapy. FE(NO) measurements were performed at presentation to the emergency department (baseline), as well as 1, 4, 6, 8, 12, and 24 hours after the initiation of therapy. FEV(1)% was measured at baseline, 1, 6, 12, and 24 hours. Subjects also were called 3 days after discharge to assess if symptoms had improved. The baseline FE(NO) was 57.5 parts per billion (ppb). There was no significant change over the first 8 hours. At 12 hours, there was an increase to 96.5 ppb (p = 0.01). Compared with baseline, all 10 subjects showed an increase at the 12-hour time point, with an average increase of 52%. The correlation between change in FE(NO) and change in FEV(1)% approached significance (p = 0.089). Subjects who improved after discharge had a greater percent increase in FE(NO) than those who did not (p = 0.043). FE(NO) measurements increase in hospitalized asthmatic patients receiving therapy. This augmentation appears to be associated with improvements in FEV(1). Asthmatic patients who show a greater increase in FE(NO) may have better outcomes after discharge.

Cell carcinoma of the paranasal sinuses and skull base

PURPOSE

To evaluate patients with squamous cell carcinoma of the paranasal sinus and skull base for factors that might predict clinical outcome.

METHODS

A multi-institutional 13-year retrospective review of anterior skull base malignancies.

RESULTS

Of 73 patients with anterior skull base malignancies, squamous cell carcinoma was the most prevalent-30 patients or 41%. Twenty-three patients underwent craniofacial surgery with or without adjuvant chemotherapy. Seven patients, deemed unresectable or not willing to have surgery, were treated with standard radiation protocols often with chemotherapy. The 3- and 5-year survival rates after surgery were 32% and 16%, respectively, compared to a 28% survival rate at 3 and 5 years for the nonsurgical group. Most tumors were in advanced stages accounting for a relatively poor survival in both groups. A Cox regression analysis demonstrated that age (P = .0172) was an independent determinant of poor outcome. Although 3- and 5-year survival of tumors free of sphenoid sinus, dura, retromaxillary, and ptyerygoid space, and orbit treated with surgery showed no significant difference to those patients with involvement, their median time of survival was increased for all anatomical regions.

CONCLUSIONS

Squamous cell carcinoma of the sinus invading the skull base carries a very poor prognosis regardless of treatment modality. Surgery with adjunctive radiotherapy and/or chemotherapy offers a survival advantage over nonsurgical methods, but treatment should be individualized weighing prognostic factors, such as age, stage, and anatomical extension with morbidity of treatment.

Blood lead levels and specific attention effects in young children

The detrimental effects of early exposure to lead are credible and persistent, but there is presently no agreement on a safe threshold for circulating lead levels. Although several research groups have found significantly poorer cognitive performance in children who have whole blood levels as low as 5 microg/dL, most government agencies, including the EPA and the CDC, continue to use 10 microg/dL as the criterion for concern in public health advisories. Prior research has consistently indicated a negative relation between lead levels and attention. Similarly, the results of the present study show a relation between blood lead level and neurobehavioral outcome in 7-year-old children (N=506). Higher lead levels were associated significantly with decreased scores on measures of intelligence (i.e., overall, performance and verbal IQ), lengthened reaction time, hyperactivity, and social and delinquent behavior problems. Importantly, the present study documents a significant negative impact of blood lead levels on attention, but not impulsivity, in early elementary age children, further delineating the specific aspects of attention related to blood lead concentrations. Analyses were also conducted to identify a "safe" blood lead level threshold. Visual inspection of non-parametric regression plots suggested a gradual linear dose-response relationship for each endpoint. None of the neurobehavioral outcomes assessed showed evidence of a threshold under which lead levels appear to "safe". In light of the consistency of these findings with those of several other groups, it is advisable to consider whether the threshold for an acceptable blood lead level should be reduced.

Extreme prematurity: an alcohol-related birth effect

BACKGROUND

Rates of preterm delivery, a major proximate cause of perinatal morbidity and mortality, have been increasing. Prenatal alcohol exposure has been implicated in preterm delivery, although results have been inconsistent due to inadequate control for confounding factors, insufficient power, unreliable and inaccurate assessment of both exposure and gestational age, and lack of stratification of prematurity into severity levels. The purpose of this study was to examine the relation between maternal alcohol, cocaine and cigarette use during pregnancy, and extreme and mild preterm birth.

METHODS

Three thousand one hundred thirty consecutive gravidas were followed prospectively for antenatal substance use and had ultrasound confirmed pregnancy dating.

RESULTS

Alcohol and cocaine, but not cigarette use, were associated with increased risk of extreme preterm delivery after control for potential confounders. For every unit increase in alcohol exposure, risk of extreme preterm delivery increased significantly [odds ratio (OR) 34.8]. Furthermore, in women aged 30+, alcohol exposure was associated with mild prematurity. Abstention from alcohol while continuing to use cocaine and tobacco was related to a decrease in extreme prematurity of 41%.

CONCLUSIONS

The risk of extreme preterm delivery associated with alcohol use is substantial and similar in magnitude to other well-recognized risks. Increased accuracy in identifying exposure and the use of ultrasound to confirm gestational age dating likely contributed to the findings of the current study. These findings suggest that eliminating pregnancy alcohol use might substantially reduce the risk of preterm delivery.

Intermittent hormone therapy in nonmetastatic prostate cancer

PURPOSE

The object of this study was to evaluate the duration of response to intermittent androgen deprivation (IAD) in patients with nonmetastatic recurrent or localized prostate cancer.

PATIENTS AND METHODS

One hundred ten patients received IAD from February 1992 to February 2005. One hundred three patients were treated after failure of primary radiation therapy and/or prostatectomy, with the remaining 7 patients treated primarily with IAD. The median duration of treatment cycle was 6 months. Patients were considered resistant to hormone therapy if the prostate-specific antigen (PSA) level increased, with castrate levels of testosterone. At the time of initial diagnosis, the median Gleason score was 7 (range, 4-9), and tumor stages were as follows: T1/T2 (n = 73), T3 and T4 N1 (n = 34), and other (n = 3). The median PSA at the initiation of IAD was 8.25 ng/mL.

RESULTS

The median follow-up after beginning IAD was 45.5 months. Patients received a median of 2 cycles (range, 1-9 cycles). Ninety-four of 110 patients (85.5%) remained responsive to IAD. Sixteen patients (14.5%) progressed to become refractory to primary hormone treatment. Patients with a higher tumor stage (T3 and T4) were significantly more likely to develop resistance. The median time to become refractory to hormone therapy was 47.9 months (range, 9.4-93.4 months). Five patients were put on secondary continuous hormone treatment, and 3 of them developed resistance at a median of 9 months. One patient was put on a secondary IAD and was still responding at the last follow-up.

CONCLUSION

With 85.5% of the original patient population still responding to the primary hormone therapy at 45.5 months of follow-up, IAD appears to be a viable option for patients with biochemical failure after local radiation therapy. A pattern of shortening time between cycles and an increasing nadir PSA level with each successive cycle is consistent with the gradual development of hormone resistance.

Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes

BACKGROUND

A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence.

OBJECTIVE

To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA.

METHODS

A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval.

RESULTS

There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001).

CONCLUSION

Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates.

CLINICAL IMPLICATIONS

Patients with asthma who leave AMA are at increased risk of relapse.

Isolation of Aspergillus in critically ill patients: a potential marker of poor outcome

OBJECTIVE

Recent reports have suggested a rising incidence of pulmonary aspergillosis in intensive care unit (ICU) patients. The aim of this study was to determine the clinical significance of isolating Aspergillus from respiratory samples of critically ill patients.

DESIGN

Retrospective review of medical records.

SETTING

Tertiary medical center that has a large cancer center.

PATIENTS

All patients admitted to the ICU between January 1998 and August 2004, in whom Aspergillus was isolated from respiratory samples or lung tissue.

INTERVENTION

None.

RESULTS

The charts of 104 patients were reviewed. Aspergillus was isolated for a mean of 6.6 days after ICU admission. Thirty-three percent of patients had hematological malignancy, 10% had absolute neutropenia, 14% had bone marrow transplant, 11% had HIV infection, and 22% had chronic obstructive pulmonary disease. Upon admission to ICU, 79%, 43%, and 19% were on antibiotics, corticosteroids, or immunosuppressive therapy, respectively. Ninety percent of patients required mechanical ventilation. The mean Acute Physiologic and Chronic Health Evaluation II score on ICU admission was 20.6, with predicted mortality of 35.5%. However, the actual ICU mortality rate for the cohort was 50%. Twenty-eight percent of patients were diagnosed with probable or definite invasive pulmonary aspergillosis, and 72% had Aspergillus colonization. On univariate analysis, the significant clinical differences between the 2 groups were the presence of neutropenia (P < .05), immunosuppressants (P < .05), antibiotics (P < .05), or bone marrow transplant (P < .05). The differences in Acute Physiologic and Chronic Health Evaluation II score, the need for mechanical ventilation, ICU length of stay, and ICU mortality were not statistically significant. On multivariate analysis, the following factors were independently associated with invasive diseases, bone marrow transplantation (P < .01), hematological malignancy (P = .02), and broad-spectrum antibiotics (P = .02).

CONCLUSION

Isolation of Aspergillus in critically ill patients is a poor prognostic marker and is associated with high mortality irrespective of invasion or colonization. Those who are neutropenic, on immunosuppressive therapy, on broad-spectrum antibiotics, or had bone marrow transplantation are more likely to have invasive pulmonary aspergillosis.

Somatic complaints in children and community violence exposure

Somatic complaints of children in primary care settings often go unexplained despite attempts to determine a cause. Recent research has linked violence exposure to stress symptomatology and associated somatic problems. Unknown, however, is whether specific physical symptom complaints can be attributed, at least in part, to violence exposure. Urban African-American 6- and 7-year-old children (N = 268), residing with their biological mothers, recruited before birth, and without prenatal exposure to hard illicit drugs participated. Children and mothers were evaluated in our hospital-based research laboratory, with teacher data collected by mail. Community violence exposure (Things I Have Seen and Heard), stress symptomatology (Levonn), and somatic complaints (teacher-and self-report items) were assessed. Additional data collected included prenatal alcohol exposure, socioeconomic status, domestic violence, maternal age, stress, somatic complaints and psychopathology, and child depression, abuse, and gender. Community violence witnessing and victimization were associated with stress symptoms (r = .26 and .25, respectively, p < .001); violence victimization was related to decreased appetite (r = .16, p < .01), difficulty sleeping (r = .21, p < .001), and stomachache complaints (r = .13, p < .05); witnessed violence was associated with difficulty sleeping (r = .13, p < .05) and headaches (r = .12, p < .05). All associations remained significant after control for confounding. Community violence exposure accounted for 10% of the variance in child stress symptoms, and children who had experienced community violence victimization had a 28% increased risk of appetite problems, a 94% increased risk of sleeping problems, a 57% increased risk of headaches, and a 174% increased risk of stomachaches. Results provide yet another possibility for clinicians to explore when treating these physical symptoms in children.

The load of Chlamydia pneumoniae in the Alzheimer's brain varies with APOE genotype

Studies from this laboratory have indicated that the intracellular eubacterial respiratory pathogen Chlamydophila (Chlamydia) pneumoniae is commonly found in brain regions displaying characteristic neuropathology in patients with late-onset Alzheimer's disease (AD) but not in congruent samples from non-AD control individuals. In later work, we provided evidence suggesting that some relationship exists between the APOE epsilon4 gene product and the pathobiology of this organism. In the present report, in situ hybridization analyses indicated that the number of C. pneumoniae-infected cells in affected brain regions of epsilon4-bearing AD patients was higher overall than that in congruent brain regions from AD patients lacking that allele. Quantitative real-time PCR analyses of AD brain tissue samples demonstrated that actual bacterial burden in those samples varied over several orders of magnitude, but that samples from epsilon4-bearing patients did have significantly higher bacterial loads than did congruent samples from patients without the allele (ANOVA, p<0.05). These results may explain in part the observations that epsilon4-bearing individuals have a higher risk of developing AD, and that such patients progress more rapidly to cognitive dysfunction than do individuals lacking this allele.

Accuracy of estimated fetal weight in shoulder dystocia and neonatal birth injury

OBJECTIVE

This study was undertaken to determine whether there is any difference in the rate of error of estimated fetal weight (EFW) in cases of shoulder dystocia compared with controls.

STUDY DESIGN

Women whose delivery was complicated by shoulder dystocia were studied and compared with a control group matched for parity, race, labor type (spontaneous or induced), and birth weight (BW). Accuracy (%) was defined as [(EFW-BW)/BW] x 100. The primary outcome of the study was rate of EFW underestimation error 20% or greater.

RESULTS

During the 5-year study period, there were 206 cases of shoulder dystocia that met all study criteria. There was no difference in the number of patients that had EFW underestimation error 20% or greater (shoulder dystocia 9.8% vs control 12.8%; P = .38). There was also no difference in the number of patients that had EFW underestimation error 20% or greater between shoulder dystocia with and without injury (injury 8.3% vs no injury 7.1%; P = .79).

CONCLUSION

EFW underestimation error in cases of shoulder dystocia is an infrequent event and does not occur more often than in deliveries without shoulder dystocia.