Inpatient residential treatment program for combat-related posttraumatic stress disorder (PTSD): Results from the 2020 Artsakh (Nagorno-Karabakh) War

Inpatient residential treatment programs to evaluate active military service members for potential return to service or discharge are considered an integral component of rehabilitation for trauma related conditions. This retrospective study was conducted on combat-exposed military service members who were admitted to an inpatient residential treatment program for evaluation of fitness to serve and treatment of trauma related conditions. The PTSD Checklist for DSM-5 (PCL-5) was used to screen for PTSD, determine symptom severity, and monitor symptom change. At the time of admission, 54.3% of the service members met the provisional PTSD diagnosis, whereas at the time of discharge, 16.28% of the service members met the provisional diagnostic criteria. The most common symptoms rated moderately or higher were sleep troubles, followed by super alert, disturbing memories, feeling upset, disturbing dreams, physical reactions, avoiding memories, and negative feelings. Paired t-test results comparing the PCL-5 five Subscales and Total Score at the time of admission and discharge showed significant reductions. The five symptoms that improved the least were sleep troubles, feeling upset, avoiding memories, difficulty concentrating, and trouble remembering. The successful creation and implementation of an Armenian version of the PCL-5 was realized and, when put to the test, aided in screening, diagnosing, and monitoring PTSD symptoms among Armenian Army Service members. The results suggest that PTSD symptoms in an inpatient residential treatment program decreased over time. The symptoms that bothered the service members at most during the time of admission, however, improved the least at the time of discharge.

Development and presentation of an objective risk stratification tool for healthcare workers when dealing with the COVID-19 pandemic in the UK: risk modelling based on hospitalisation and mortality statistics compared with epidemiological data

OBJECTIVES

Healthcare workers have greater exposure to SARS-CoV-2 and an estimated 2.5-fold increased risk of contracting COVID-19 than the general population. We wished to explore the predictive role of basic demographics to establish a simple tool that could help risk stratify healthcare workers.

SETTING

We undertook a review of the published literature (including multiple search strategies in MEDLINE with PubMed interface) and critically assessed early reports on preprint servers. We explored the relative risk of mortality from readily available demographics to identify the population at the highest risk.

RESULTS

The published studies specifically assessing the risk of healthcare workers had limited demographics available; therefore, we explored the general population in the literature. Clinician demographics: Mortality increased with increasing age from 50 years onwards. Male sex at birth, and people of black and minority ethnicity groups had higher susceptibility to both hospitalisation and mortality. Comorbid disease. Vascular disease, renal disease, diabetes and chronic pulmonary disease further increased risk. Risk stratification tool: A risk stratification tool was compiled using a white female aged <50 years with no comorbidities as a reference. A point allocated to risk factors was associated with an approximate doubling in risk. This tool provides numerical support for healthcare workers when determining which team members should be allocated to patient facing clinical duties compared with remote supportive roles.

CONCLUSIONS

We generated a tool that provides a framework for objective risk stratification of doctors and healthcare professionals during the COVID-19 pandemic, without requiring disclosure of information that an individual may not wish to share with their direct line manager during the risk assessment process. This tool has been made freely available through the British Medical Association website and is widely used in the National Health Service and other external organisations.

National outbreak of Pseudomonas aeruginosa associated with an aftercare solution following piercings, July to September 2016, England

We report a national Pseudomonas aeruginosa outbreak from a common source following piercings between July and September 2016 in England. The multi-agency outbreak investigation included active case finding, microbiological testing of environmental samples and case specimens including Variable Number Tandem Repeat (VNTR) typing and a retrospective cohort study. Overall, 162 outbreak cases (29 confirmed, 14 probable and 119 possible) and 14 non-outbreak cases were identified; all confirmed cases had ear piercings (93% cartilage). Outbreak cases were predominantly female (95%) and had a median age of 18 years (interquartile range: 13-56 years). Nineteen outbreak cases required surgery under general anaesthetic The same outbreak VNTR type (11,3,5,3,3,3,6,4,7) was isolated from bottles of an aftercare solution from a single manufacturer and in specimens from confirmed cases who attended eight different piercing studios supplied with this product. In the cohort study, use of aftercare solution was associated with becoming a case (aOR: 4.60, 95% confidence interval: 1.65-12.90). Environmental, microbiological and epidemiological investigations confirmed that contamination during production of aftercare solution was the source of this national outbreak; highlighting challenges in the regulation of a cosmetic products used in the piercing industry and that guidance on piercing aftercare may need to be reviewed.

Correction to: Adipokines and the insulin resistance syndrome in familial partial lipodystrophy caused by a mutation in lamin A/C

The authors regret that Alexandra Bargiota's name was spelt incorrectly in the author list. The details given in this correction are correct.

Same-Sex Domestic Violence: Why Victims are More at Risk

The purpose of this study was to examine police officers' general knowledge, experience and training in the area of same-sex domestic violence. A survey was administered to 91 police officers from 5 towns in Illinois. The study revealed that a majority of officers had encountered at least one same-sex domestic violence call within the last six months. In contrast, officers reported very little training in their departments regarding this issue. While previous research studies suggest that same-sex domestic violence and opposite-sex domestic violence have a roughly equivalent frequency rate, the current study finds that police officers are encountering same-sex domestic violence on a regular basis. However, a lack of training may render cases of same-sex violence more difficult for officers, as training in same-sex violence is not as readily available as is training for opposite-sex violence.

Diabetes management of elective hospital admissions

AIMS

At any given time, people with diabetes occupy approximately 10-20% of acute hospital beds. In addition, diabetes is associated with a greater length of stay. Patients undergoing elective procedures occupy approximately 50% of hospital beds. The aim of this 12-month project was to improve the quality of diabetes care for elective inpatients. The primary outcome measure was length of stay.

METHODS

A team was established to improve the quality of care and reduce the length of stay of all patients admitted electively with diabetes. Specific areas of focus were surgical pre-assessment, planning the admission, post-operative care and planning a safe discharge. A retrospective audit of all elective patients with a coded diagnosis of diabetes admitted between June 2008 and June 2009 was performed.

RESULTS

Comparing the year of the project with the preceding year day-case rates for patients with diabetes increased by 34.8% for diabetes vs. 13.7% for the total hospital population (P for difference=0.048). There was a significant fall in diabetes length of stay of 0.34 days comparing 2008 and 2009 (P=0.040). Over the same period, we have shown a smaller reduction in length of stay for all other admissions of 0.08 days (p=0.039).

CONCLUSION

A team specifically employed to focus on elective inpatient diabetes care have a significant impact on length of stay of this patient group with potential cost savings.

Diabetic complications and glycaemic control in remote North Africa

BACKGROUND

Delivery of diabetes services in resource-poor areas of Africa is difficult. Control is often poor and complications are common. However, adequate robust surveys are uncommon, particularly in remote rural areas. This makes needs assessment difficult and health-care planning impossible.

AIM

To accurately assess the glycaemic control and burden of complications in a group of diabetic patients from a remote area of a resource-limited north African country.

DESIGN

Prospective cohort study.

METHODS

Over a 6-week period, all patients attending the diabetic clinic at Mekelle Hospital in northern Ethiopia were intensively assessed, using imported western technology as necessary. Glycated haemoglobin (HbA(1c)), lipid profile, serum creatinine and urinary albumin-creatinine ratio were measured. Complications were assessed as accurately as possible, including examination of fundi by an ophthalmic specialist, and biosthesiometry for neuropathy.

RESULTS

There were 105 patients, mean (+/- SD) age 41 +/- 16 years and diabetes duration 7 +/- 6 years. There were 74 (70%) males, and 69 (66%) on insulin. Median body mass index was low at 20.6 kg/m(2), but mean HbA(1c) high at 11.3 +/- 2.8% (68% had an HbA(1c) over 10.0%). Cataract (12%), retinopathy (21%), neuropathy (41%) and microalbuminuria (51%) were common; but nephropathy (2%) was rare, as was large vessel disease (6% had peripheral vascular disease, and none had coronary artery disease or cerebrovascular disease). Risk factors such as hypertension (5%) and smoking (2%) were uncommon, and lipid profiles were generally good.

DISCUSSION

We conclude that in this severely resource-limited area of North Africa, glycaemic control amongst diabetic patients is very poor. Neuropathy, retinopathy and microalbuminuria are common; but large vessel disease risk factors are beneficial, and macroangiopathy prevalence is low. Scattered populations, shortage of drugs and insulin and lack of diabetes team care are major factors behind these serious issues of diabetic control and complications.

Proton magnetic resonance spectroscopy in frontotemporal dementia

This study of frontotemporal dementia (FTD) was carried out to determine whether MR spectroscopy can provide an in vivo marker for the neuronal loss and gliosis that occur in this condition. We compared spectra in frontal and temporal regions known to be affected early in the course of the disease with spectra in the parietal lobe that is spared until late stages of FTD. We were interested in the relative concentrations of two compounds, NAA (a marker of neuronal integrity) and mI (a marker of gliosis), expressed as ratios to creatine (a relatively stable brain constituent). MR spectroscopy was performed on the temporal, parietal, and anterior cingulate cortices of five patients with the established semantic dementia form of FTD, two patients with the frontal form of FTD and 13 age matched controls. Structural MRI and neuropsychometry were also performed. Patients with FTD had reduced NAA/Cr in frontal and temporal, but not parietal lobes. The two patients with the frontal form of FTD had increased mI/Cr in their cingulate cortices. These data show for the first time that MR spectroscopy can reveal regionally selective abnormalities in patients with FTD. This opens up the possibility of using MR spectroscopy as a clinical tool to identify earlier presentations of the condition.

Diabetic ketoacidosis complicated by axillary vein thrombosis

A case is presented of a 39-year-old male with Down's Syndrome, who also had type 1 diabetes of 22 years duration. He presented with diabetic ketoacidosis (DKA)-arterial blood pH 7.17, plasma bicarbonate 13.6mmol/l, plasma glucose 26.4mmol/l and urine heavily positive for ketones. He recovered with standard intravenous fluid and insulin treatment, but on the third day of admission developed a swollen left arm (which had not been used for intravenous cannulation). Doppler ultrasound confirmed a left axillary vein thrombosis. This slowly resolved with anticoagulation. Review of the available literature revealed that though arterial thrombosis is a common complication of DKA, venous thromboembolism is surprisingly rare, and there appear to be no previous specific reports of axillary vein thrombosis complicating DKA.

Comparison of image quality, diagnostic confidence and interobserver variability in contrast enhanced MR angiography and 2D time of flight angiography in evaluation of carotid stenosis

The aim of this study was to compare image quality, level of diagnostic confidence and interobserver agreement in assessment of carotid stenosis with contrast enhanced MR angiography (CE MRA) in comparison with 2D time of flight MR angiography (2D TOF MRA). 60 carotid arteries in 30 patients were examined by three observers. Image quality and diagnostic confidence were assessed on the basis of a visual analogue scale. Interobserver variability was assessed with the help of intraclass correlation coefficient. Median values on the visual analogue scale for image quality and diagnostic confidence were higher for CE MRA compared with 2D TOF MRA for all three observers. Higher intraclass correlation values were recorded for interobserver variability for CE MRA compared with 2D TOF MRA both for visual estimation of carotid stenosis as well as for measurement of carotid stenosis on the basis of North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) criteria. CE MRA provides better image quality, higher level of diagnostic confidence and more interobserver agreement compared with 2D TOF MRA.

Should universal hepatitis B immunisation be introduced in the UK?

Yes. But how?

Adipokines and the insulin resistance syndrome in familial partial lipodystrophy caused by a mutation in lamin A/C

AIMS/HYPOTHESIS

Familial partial lipodystrophy (FPLD) and obesity are both associated with increased risks of type 2 diabetes and cardiovascular disease. Although adipokines have been implicated, few data exist in subjects with FPLD; therefore we investigated a family with FPLD due to a lamin A/C mutation in order to determine how abnormalities of the plasma adipokine profile relate to insulin resistance and the metabolic syndrome.

METHODS

Plasma levels of adiponectin, leptin, resistin, IL-1beta, IL-6 and TNF-alpha in 30 subjects (ten patients, 20 controls) were correlated with indices of metabolic syndrome.

RESULTS

Compared with controls, FPLD patients had significantly lower plasma levels of adiponectin (3.7+/-1.0 in FDLP cases vs 7.1+/-0.72 mug/ml in controls, p=0.02), leptin (1.23+/-0.4 vs 9.0+/-1.3 ng/ml, p=0.002) and IL-6 (0.59+/-0.12 vs 1.04+/-0.17 pg/ml, p=0.047) and elevated TNF-alpha (34.8+/-8.1 vs 13.7+/-2.7 pg/ml, p=0.028), whereas IL-1beta and resistin were unchanged. In both groups, adiponectin levels were inversely correlated with body fat mass (controls, r=-0.44, p=0.036; FDLP, r=-0.67, p=0.025), insulin resistance (controls, r=-0.62, p=0.003; FDLP, r=-0.70, p=0.025) and other features of the metabolic syndrome. TNF-alpha concentrations were positively related to fat mass (controls, r=0.68, p=0.001; FDLP, r=0.64, p=0.048) and insulin resistance (controls, r=0.86, p=0.001; FDLP, r=0.75, p=0.013). IL-6, IL-1beta and resistin did not demonstrate any correlations with the metabolic syndrome in either group.

CONCLUSIONS/INTERPRETATION

Low adiponectin and leptin and high TNF-alpha were identified as the major plasma adipokine abnormalities in FPLD, consistent with the hypothesis that low adiponectin and high TNF-alpha production may be mechanistically related, and perhaps responsible for the development of insulin resistance and cardiovascular disease in FPLD.

Crural laceration--diagnosis and management of an unusual penile injury

Crural laceration is a previously unreported variant of penile trauma. We present a case that was diagnosed using MRI and managed conservatively with a successful functional outcome.

Hyperglycaemic crises and lactic acidosis in diabetes mellitus

Diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and lactic acidosis represent three of the most serious acute complications of diabetes. There have been some advances in our understanding of the pathogenesis of these conditions over the last three decades, together with more uniform agreement on their treatment and innovations in technology. Accordingly their incidence, morbidity, and mortality are decreasing, but at rates that fall short of our aspirations. Hyperglycaemic crises in particular remain an important cause of morbidity and mortality in diabetic populations around the world. In this article, understanding of these conditions and advances in their management, and the available guidelines for their treatment, are reviewed. As far as is possible, the recommendations are based on clear published evidence; failing that, what is considered to be a common sense synthesis of consensus guidelines and recommendations is provided.

Comparison of the pathology of cerebral white matter with post-mortem magnetic resonance imaging (MRI) in the elderly brain

White matter lesions (WML) on magnetic resonance imaging (MRI) brain scans are associated with ageing. They are unrelated to specific disorders, and their impact on cognitive and other brain functions is poorly characterized. Pathological studies often omit systematic survey of WML because of the need to study multiple full coronal tissue blocks, and uncertainty over the significance of lesions identified in periventricular and deep subcortical regions. Post-mortem MRI provides a means of mapping WML but the sensitivity and specificity of the method are unresolved. In this study post-mortem MRI of WML in fixed brain slices was compared with pathology in 33 brains donated to the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS). This study shows that MRI detection of WML was less sensitive than pathology: periventricaular lesions (PVL) sensitivity = 95% (87-99%), specificity = 71% (44-90%); deep subcortical lesions (DSCL) sensitivity = 86% (79-93%), specificity = 80% (72-88%). False negative MRI was associated with milder pathology, but lesions detected by myelin attenuation alone showed both microglial and endothelial activation. Therefore post-mortem MRI of formalin-fixed brain slices is a reliable method to obtain systematic data on the severity and distribution of cerebral white matter disease, and appears to detect those WML most likely to have clinical impact.

Intensified treatment of type 2 diabetes--positive effects on blood pressure, but not glycaemic control

BACKGROUND

Since publication of the UK Prospective Diabetes Study (UKPDS) in 1998, there has been a clear evidence base for tight glycaemic (HBA(1c) < 7.0%) and blood pressure (BP < 140/85 mmHg) control.

AIM

To determine the effect of UKPDS-based intensified glycaemic and BP targets on the care of type 2 diabetic patients attending a routine diabetes clinic.

DESIGN

Two surveys, each of 500 consecutively attending type 2 diabetic patients.

METHODS

The first survey was in a 3-month period in 1999, shortly after publication of the UKPDS study. The second was identical, but 2 years later. Glycaemic control (by DCCT-aligned HBA(1c)), BP and treatment details were recorded in both.

RESULTS

BP control was significantly improved in the second survey (mean +/- SD systolic BP from 151 +/- 25 to 146 +/- 26 mmHg, p = 0.001; diastolic from 77 +/- 13 to 72 +/- 12 mmHg, p < 0.0001) and the proportion of patients on anti-hypertensive treatment increased from 33% to 60% (p < 0.0001). Mean HbA(1c) however remained unchanged (8.7 +/- 1.8% in 1999 vs. 8.5 +/- 1.8% in 2001), although there was evidence of more intensive treatment patterns, with declining numbers on diet alone and more on oral agents and/or insulin.

DISCUSSION

Intensified BP control may be achievable within the confines of routine diabetes care, but achievement of optimal glycaemic targets remains problematic.

Non-invasive assessment of extracranial-intracranial bypass grafts using advanced ultrasound technology

There have been significant developments in ultrasound technology in the last few years which have resulted in an increase in the clinical value of this technique. An illustrative case is presented of how ultrasound technology has been used in the intraoperative and postoperative period to evaluate graft patency and function in patients undergoing extracranial-intracranial bypass graft surgery.

Neuralgic amyotrophy as a presenting feature of infective endocarditis

A 35 year old man presented to his general practitioner with severe right shoulder pain and subsequent weakness and wasting of the muscles in the affected shoulder girdle three weeks after a dental filling. His symptoms persisted despite standard treatment. He developed malaise, night sweats, weight loss, a petechial rash and a microcytic anaemia. On admission to hospital three months after the start of his symptoms he had also developed splenomegaly and the murmur of aortic regurgitation. Investigations confirmed the diagnoses of infective endocarditis and neuralgic amyotrophy. In this case neuralgic amyotrophy appears to have been the presenting feature of infective endocarditis. This association has not previously been described.

Examining associations between childhood asthma and traffic flow using a geographic information system

Using geographic information systems (GIS) and routinely collected data, we explored whether childhood residence near busy roads was associated with asthma in a low-income population in San Diego County, California. We examined the locations of residences of 5,996 children [less than/equal to] 14 years of age who were diagnosed with asthma in 1993 and compared them to a random control series of nonrespiratory diagnoses (n = 2,284). Locations of the children's residences were linked to traffic count data at streets within 550 ft. We also examined the number of medical care visits in 1993 for children with asthma to determine if the number of visits was related to traffic flow. Analysis of the distribution of cases and controls by quintiles and by the 90th, 95th, and 99th percentiles of traffic flow at the highest traffic street, nearest street, and total of all streets within a 550-ft buffer region did not show any significantly elevated odds ratios. However, among cases, those residing near high traffic flows (measured at the nearest street) were more likely than those residing near lower traffic flows to have two or more medical care visits for asthma than to have only one visit for asthma during the year. The results of this exploratory study suggest that higher traffic flows may be related to an increase in repeated medical visits for asthmatic children. Repeated exposure to particulate matter and other air pollutants from traffic exhaust may aggravate asthmatic symptoms in individuals already diagnosed with asthma.

Examining associations between childhood asthma and traffic flow using a geographic information system

Using geographic information systems (GIS) and routinely collected data, we explored whether childhood residence near busy roads was associated with asthma in a low-income population in San Diego County, California. We examined the locations of residences of 5,996 children [less than/equal to] 14 years of age who were diagnosed with asthma in 1993 and compared them to a random control series of nonrespiratory diagnoses (n = 2,284). Locations of the children's residences were linked to traffic count data at streets within 550 ft. We also examined the number of medical care visits in 1993 for children with asthma to determine if the number of visits was related to traffic flow. Analysis of the distribution of cases and controls by quintiles and by the 90th, 95th, and 99th percentiles of traffic flow at the highest traffic street, nearest street, and total of all streets within a 550-ft buffer region did not show any significantly elevated odds ratios. However, among cases, those residing near high traffic flows (measured at the nearest street) were more likely than those residing near lower traffic flows to have two or more medical care visits for asthma than to have only one visit for asthma during the year. The results of this exploratory study suggest that higher traffic flows may be related to an increase in repeated medical visits for asthmatic children. Repeated exposure to particulate matter and other air pollutants from traffic exhaust may aggravate asthmatic symptoms in individuals already diagnosed with asthma.

Palaeodrainage at Uluru-Kata Tjuta National Park and implications for water resources

The stakeholders in the atypical rangeland area of Uluyu-Kata Tjufa National Park in the Northern Territory are the Aboriginal owners, hundreds of thousands of tourists, and vulnerable desert wildlife species. Sustainable water resources and maintenance of the integrity of the unique geological, ecological and cultural environment at Uluyu are major issues being addressed by the trustees of the Park. The Dune Plains area between Uluyu (Ayers Rock) and Kata Tjula (the Olgas) is the setting for a deep palaeovalley. The flat, dune-covered landscape of the present-day Dune Plains area provides no indication of the existence of the underlying palaeovalley. Integrated datasets including aeromagnetic and airborne gamma-ray spectrometric imagery, processed Landsat Thematic Mapper imagery, a digital elevation model, and water-bore logs, have enabled reconstruction of the Dune Plains palaeoriver valley. The datasets reveal a heterogeneous basement topography of domes and basins with 100 m of vertical relief (a buried 'mini-Kata Tjuia') at depth beneath the Dune Plains area, between the rock monoliths. The ancient valley became completely infilled with lake, river and wind-borne sediments during the Tertiary and Quaternary. Major faults traversing the basement beneath the area influenced early erosion and valley initiation. The palaeovalley was originally a closed valley which later evolved to a through-flowing river that fed Lake Amadeus to the north. The Dune Plains palaeovalley is now the setting for a compound bedrock- Cainozoic-sediment aquifer system which is the major source of water supply for the inhabitants and tourists of Uluyu-Kata Tjufa National Park. Major landscape units making up the Uluyu area include groundwater calcrete, sheetwash slopes of red earth, sandplains and dunefields, and modern ephemeral alluvial braidplains that are constrained to corridors afforded by swale networks. The sheetwash unit forms gently sloping aprons around outcrops and supports banded mulga shrubland. During rainfall, surface run-off acts as a 'sheetflow recharge mechanism'. This mechanism maximises water conservation allowing survival of the mulga groves and associated ecosystems. During major rainfall events, the sheetflow processes augment replenishment of the aquifer system at the base of the slopes. The palaeodrainage configuration and hydrodynamics of both the surface environment and the subsurface aquifer system are complex. The methodology used to reconstruct the Dune Plains palaeodrainage and associated aquifer system, and the hydrodynamic processes described for the Uluru area are applicable to widespread rangeland areas elsewhere across the continent. Keywords: Uluyu, Kata Tjula, Dune Plains, palaeovalley, palaeodrainage, hydrology, groundwater, aquifer, sheetwash, red earths, calcrete, hydrodynamics, mulga (Acacia aneura), run-off, run-on, recharge.

Thermometer use among Mexican immigrant mothers in California

A community-based household survey was utilized to assess the relationship between thermometer use, home treatment and utilization of health care services. Using a cross-sectional design, the study surveyed 688 low income Mexican origin mothers of children between the ages of 8 and 16 months in San Diego County. Mothers were asked how they determine that their child has fever and how often they use a thermometer. Nearly 40% of low income Mexican mothers interviewed in San Diego county never used a thermometer for determining childhood fever. Approximately two-thirds (64.7%) relied either primarily or exclusively on embodied methods such as visual observation or touch to determine fever in their child. A multivariate logistic regression analysis determined that low education and a separated or divorced marital status decreased the odds of thermometer use, whereas regular contact with the health care system doubled the likelihood of thermometer use. Mothers who relied on embodied methods were more likely to use over-the-counter medications than those who relied on thermometers; however, no significant differences were found between groups using other methods of home treatment. Fever determination modalities can be used to screen for lack of access to care and to provide for other health care needs in a culturally appropriate manner. While clinicians' expectations may include parental experience with temperature taking, current pediatric literature questions the need for home-based thermometer use. Possible alternatives to the traditional rectal thermometer might include digital thermometers and color coded thermometer strips.

Health service use among low-risk newborns after early discharge with and without nurse home visiting

BACKGROUND

To examine the potential benefits of routine nurse home visiting after early discharge, we compared health service use among low-risk newborns with and without a nurse home visit and telephone follow-up after short hospital stays.

METHODS

Records of newborns discharged routinely before (n = 83) and after (n = 91) implementation of a universal postpartum home visiting program were reviewed retrospectively. Acute care visits, rehospitalizations, and well-baby visits for newborns up to 74 days of age were compared between the groups.

RESULTS

Acute care visits, rehospitalizations, and missed well-baby visits consistently appeared less likely among newborns receiving home visiting services, in both unadjusted and adjusted analyses. Adjusting for insurance, parity, and breast-feeding, a twofold reduction in acute care visits by 14 days was significant. Although not statistically significant, adjusted analyses of acute care and missed well-baby visits revealed apparently similar patterns at all time intervals. There were too few rehospitalizations for multivariate analysis.

CONCLUSIONS

Despite the limitations of this small retrospective study, the consistency of the findings suggests potentially important benefits of home visiting services after early discharge of low-risk newborns, with substantial implications for clinical and reimbursement policy. Effects could be greater with more vulnerable populations and shorter stays than those in this study.

Magnetic resonance angiographic assessment after extracranial-intracranial bypass surgery

Extracranial-intracranial (EC-IC) bypass operation may be performed to augment the distal cerebral circulation. The bypass patency is usually assessed postoperatively with conventional cerebral angiography. Six patients are reported in whom the bypass patency was assessed using magnetic resonance angiography (MRA): Two had intracavernous carotid aneurysms, three had base of skull tumours encompassing the internal carotid artery, and one had occlusion of the right internal carotid artery with poor collateral reserve as confirmed by an acetazolamide stimulation test. Postoperative conventional cerebral angiography was also obtained in three patients for comparison. The MRA correlated reasonably well with conventional cerebral angiography in showing bypass patency, although conventional cerebral angiography was superior in demonstrating small vessels; MRA has the added advantage of showing the relative flow contribution and flow direction under physiological conditions by using targeted presaturation pulses.

The effects of maternal health behaviors and other risk factors on immunization status among Mexican-American infants

OBJECTIVE

Few studies have investigated the effect of maternal health behaviors on the utilization of childhood preventive care. We evaluated a sample of 788 Latino mother-infant pairs to determine whether, in addition to other characteristics, maternal health risk behaviors are associated with infant immunization status.

METHODOLOGY

We conducted a cross-sectional survey of Mexican origin mothers of infants 8 to 16 months of age living in San Diego County, CA. In addition to sociodemographic and health care factors, we assessed maternal behaviors such as tobacco and alcohol consumption, safety precautions, and the organization of the home environment, and examined their relation to adequate childhood immunization status.

RESULTS

When grouped together in a maternal health risk index, maternal health behaviors showed a dose-response relationship with inadequate immunization status. After controlling for confounders, each point increase on the health risk index was associated with a 20% increase in the likelihood of inadequate childhood immunizations. Marital status, parity, life stress, time lived in neighborhood, Spanish language, and child age were also important predictors.

CONCLUSION

Early identification of children at risk for underimmunization may be aided by focusing on maternal health behaviors in addition to other sociodemographic characteristics.

Infants of Mexican immigrants. Health status of an emerging population

Previous studies suggest that infants of Mexican immigrants have favorable birth outcomes despite their high socioeconomic risks. These favorable outcomes have been associated with a protective sociocultural orientation among immigrants. A sample of 708 infants of Mexican origin was assessed to determine whether such health advantages at birth are sustained at 8 to 16 months of age, or alternatively, whether their health deteriorates because of adverse socioeconomic conditions. A a cross-sectional survey was conducted in San Diego County to determine whether the child was healthy or ill (the latter indicating a history of serious infectious disease) and the factors associated with this outcome. Among infants born without serious medical problems, 74% remained healthy. For 26% of the infants, their health status was eroded by social conditions. Factors associated with illness were large households, barriers to care, and maternal characteristics including smoking, pregnancy complications, and employment. Women born in Mexico who were newcomers to the United States and spoke Spanish exclusively were more likely than non-newcomers to have ill children. In this population, one fourth of Latino infants of immigrants were at high risk for serious infectious disease despite using preventive care.

Physical exertion as a risk factor for spontaneous abortion

This study examined the association of physical exertion and spontaneous abortion in a case-control study of 607 women whose pregnancies ended in spontaneous abortion and 1,287 women who delivered livebirths in Santa Clara County, CA, in 1986 and 1987. We interviewed women about the number of hours they spent doing heavy housework and caring for young children. We also interviewed women employed during their pregnancies (71% in each group) about their work schedule; the number of hours they worked, stood, commuted, and stooped or bent; and the number of times per day they lifted weights of > 15 pounds. Standing > 8 hours per day at work was the only variable associated with increased risk [adjusted odds ratio (OR) = 1.6; 95% confidence limits (CL) = 1.1, 2.3]. This association was present only for women with a history of spontaneous abortion (adjusted OR = 2.8; 95% CL = 1.4, 5.9). Among women with this history, the OR for a second trimester abortion was 4.9 (95% CL = 1.9, 12.2). Cleaning house for > 7 hours per week or caring for young children for > 50 hours per week was associated with decreased risk (adjusted OR = 0.6, 95% CL = 0.5, 0.9; adjusted OR = 0.8, 95% CL = 0.6, 1.0, respectively). Again, these associations were specific to women with a history of spontaneous abortion (adjusted OR = 0.4, 95% CL = 0.2, 0.7; adjusted OR = 0.5, 95% CL = 0.3, 0.8). These results indicate that the specific type of physical exertion, the amount of exertion, and the context of the exertion may be important.

Successful use of the right brachial approach to perform directional atherectomy of the left coronary artery

Although directional coronary atherectomy permits the treatment of complex coronary lesions, its use is limited in patients with peripheral vascular disease by the need to use a large guiding catheter. We describe a patient in whom the right brachial approach was successfully used to perform atherectomy of a semi-protected left main coronary stenosis.

Promoting child passenger safety in children served by a health maintenance organization

A patient education program, based on the health belief model, promoting child passenger safety was developed and implemented at a health maintenance organization. The program included individual counseling by pediatricians, use of audiovisual materials and pamphlets, and (for newborn infants) a home visit by a child safety specialist. Based on parking lot observations, child safety device use increased to greater than 60% in both intervention and comparison-group children 1-4 years of age. During the child health supervision visit, pediatricians can play a leadership role in promoting child passenger safety.

Intravesical chemotherapy: combination with Tween 80 increases cytotoxicity in vitro

Tween 80 was shown to enhance significantly the cytotoxic activities of the four drugs (adriamycin, epodyl, mitomycin-c, thiotepa) most frequently administered intravesically to treat superficial bladder cancer. The colony forming ability of a human bladder cancer cell line, RT112, was measured following a 1 h exposure to each of the four drugs both alone and in combination with 0.1% and 0.3% Tween 80. Cell survival was not reduced by 0.1% Tween 80 alone. We conclude that the combination of Tween 80 with these drugs might increase the therapeutic index of intravesical chemotherapy.