Behavior Sequence Analysis of Victims' Accounts of Intimate Partner Violence

Intimate partner violence (IPV) relates not only to physical forms of abuse, but also psychological, emotional, economic, and financial controlling behaviors. IPV is a dynamic, complex phenomenon that occurs over a relatively long period of time. While several measures of IPV exist, a method that can track the progression and escalation of such behaviors in relationships could offer more understanding and highlight key intervention points for individuals in such relationships. Behavior Sequence Analysis is used in the current research to map the chain and progression of behaviors in multiple real-world cases of IPV. Results indicate clear sequential clusters of behaviors such as physical and psychological abuse, and coercive controlling behaviors such as gaslighting, restricting movement, and removing freedoms. Overall, this research stands as a foundation framework to build a greater understanding of the processes and pathways of IPV, and offers workers in the field a novel method to assist with interviewing and intervening in such cases.

Performance of a machine-learning algorithm for fully automatic LGE scar quantification in the large multi-national derivate registry

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): J. Schwitter receives research support by “ Bayer Schweiz AG “. C.N.C. received grant by Siemens. Gianluca Pontone received institutional fees by General Electric, Bracco, Heartflow, Medtronic, and Bayer. U.J.S received grand by Astellas, Bayer, General Electric. This work was supported by Italian Ministry of Health, Rome, Italy (RC 2017 R659/17-CCM698). This work was supported by Gyrotools, Zurich, Switzerland.

Background

 Late Gadolinium enhancement (LGE) scar quantification is generally recognized as an accurate and reproducible technique, but it is observer-dependent and time consuming. Machine learning (ML) potentially offers to solve this problem. 

Purpose

 to develop and validate a ML-algorithm to allow for scar quantification thereby fully avoiding observer variability, and to apply this algorithm to the prospective international multicentre Derivate cohort.

Method

 The Derivate Registry collected heart failure patients with LV ejection fraction <50% in 20 European and US centres. In the post-myocardial infarction patients (n = 689) quality of the LGE short-axis breath-hold images was determined (good, acceptable, sufficient, borderline, poor, excluded) and ground truth (GT) was produced (endo-epicardial contours, 2 remote reference regions, artefact elimination) to determine mass of non-infarcted myocardium and of dense (≥5SD above mean-remote) and non-dense scar (>2SD to <5SD above mean-remote). Data were divided into the learning (total n = 573; training: n = 289; testing: n = 284) and validation set (n = 116). A Ternaus-network (loss function = average of dice and binary-cross-entropy) produced 4 outputs (initial prediction, test time augmentation (TTA), threshold-based prediction (TB), and TTA + TB) representing normal myocardium, non-dense, and dense scar (Figure 1).Outputs were evaluated by dice metrics, Bland-Altman, and correlations. 

Results

 In the validation and test data sets, both not used for training, the dense scar GT was 20.8 ± 9.6% and 21.9 ± 13.3% of LV mass, respectively. The TTA-network yielded the best results with small biases vs GT (-2.2 ± 6.1%, p < 0.02; -1.7 ± 6.0%, p < 0.003, respectively) and 95%CI vs GT in the range of inter-human comparisons, i.e. TTA yielded SD of the differences vs GT in the validation and test data of 6.1 and 6.0 percentage points (%p), respectively (Fig 2), which was comparable to the 7.7%p for the inter-observer comparison (n = 40). For non-dense scar, TTA performance was similar with small biases (-1.9 ± 8.6%, p < 0.0005, -1.4 ± 8.2%, p < 0.0001, in the validation and test sets, respectively, GT 39.2 ± 13.8% and 42.1 ± 14.2%) and acceptable 95%CI with SD of the differences of 8.6 and 8.2%p for TTA vs GT, respectively, and 9.3%p for inter-observer. 

Conclusions

 In the large Derivate cohort from 20 centres, performance of the presented ML-algorithm to quantify dense and non-dense scar fully automatically is comparable to that of experienced humans with small bias and acceptable 95%-CI. Such a tool could facilitate scar quantification in clinical routine as it eliminates human observer variability and can handle large data sets.

COVID-19 Impact on Acute Ischemic Stroke Treatment at 9 Comprehensive Stroke Centers across Los Angeles

Objective

To describe the impact of COVID-19 on acute cerebrovascular disease care across 9 comprehensive stroke centers throughout Los Angeles County (LAC).

Methods

Volume of emergency stroke code activations, patient characteristics, stroke severity, reperfusion rates, treatment times, and outcomes from February 1 to April 30, 2020, were compared against the same time period in 2019. Demographic data were provided by each participating institution.

Results

There was a 17.3% decrease in stroke code activations across LAC in 2020 compared to 2019 (1,786 vs. 2,159, respectively, χ² goodness of fit test p < 0.0001) across 9 participating comprehensive stroke centers. Patients who did not receive any reperfusion therapy decreased by 16.6% in 2020 (1,527) compared to 2019 (1,832). Patients who received only intravenous thrombolytic (IVT) therapy decreased by 31.8% (107 vs. 157). Patients who received only mechanical thrombectomy (MT) increased by 3% (102 vs. 99). Patients who received both IVT and MT decreased by 31.8% (45 vs. 66). Recanalization treatment times in 2020 were comparable to 2019. CSCs serving a higher proportion of Latinx populations in the eastern parts of LAC experienced a higher incidence of MT in 2020 compared to 2019. Mild increase in stroke severity was seen in 2020 compared to 2019 (8.95 vs. 8.23, p = 0.046). A higher percentage of patients were discharged home in 2020 compared to 2019 (59.5 vs. 56.1%, p = 0.034), a lower percentage of patients were discharged to skilled nursing facility (16.1 vs. 20.7%, p = 0.0004), and a higher percentage of patients expired (8.6 vs. 6.3%, p = 0.008).

Conclusion

LAC saw a decrease in overall stroke code activations in 2020 compared to 2019. Reperfusion treatment times remained comparable to prepandemic metrics. There has been an increase in severe stroke incidence and higher volume of thrombectomy treatments in Latinx communities within LAC during the pandemic of 2020. More patients were discharged home, less patients discharged to skilled nursing facilities, and more patients expired in 2020, compared to the same time frame in 2019.

Macroscopic properties of high-order harmonic generation from molecular ions

High harmonic spectroscopy utilizes the extremely nonlinear optical process of high-order harmonic generation (HHG) to measure complex attosecond-scale dynamics within the emitting atom or molecule subject to a strong laser field. However, it can be difficult to compare theory and experiment, since the dynamics under investigation are often very sensitive to the laser intensity, which inevitably varies over the Gaussian profile of a typical laser beam. This discrepancy would usually be resolved by so-called macroscopic HHG simulations, but such methods almost always use a simplified model of the internal dynamics of the molecule, which is not necessarily applicable for high harmonic spectroscopy. In this Letter, we extend the existing framework of macroscopic HHG so that high-accuracy ab initio calculations can be used as the microscopic input. This new (to the best of our knowledge) approach is applied to a recent theoretical prediction involving the HHG spectra of open-shell molecules undergoing nonadiabatic dynamics. We demonstrate that the predicted features in the HHG spectrum unambiguously survive macroscopic response calculations, and furthermore they exhibit a nontrivial angular pattern in the far field.

Currently available medical engineering degrees in the UK. Part 2: Postgraduate degrees

This paper considers taught medical engineering MSc degrees, based on mechanical engineering, which are provided in the UK. Currently there are 19 institutions which provide such postgraduate degree programmes. These are the University of Aberdeen, University of Bath, University of Bradford, Brunel University, University of Dundee, University of Hull, Imperial College London, Keele University, King's College London, University of Leeds, University of Liverpool, University of Nottingham, University of Oxford, Queen Mary University of London, University of Southampton, University of Strathclyde, University of Surrey, University of Ulster, and University of Warwick. While most courses are delivered on a 1 year full-time basis, other delivery modes are also available. Relatively few modules are offered as distance learning or short courses. A wide range of modules are offered by the various universities for the different taught MSc degrees. Common modules include biomaterials and biomechanics. The medical-engineering-related modules offered by a number of universities are also made available to students on allied MSc programmes and undergraduate degrees in medical engineering.

Currently available medical engineering degrees in the UK. Part 1: Undergraduate degrees

This paper reviews mechanical-engineering-based medical engineering degrees which are currently provided at undergraduate level in the UK. At present there are 14 undergraduate degree programmes in medical engineering, offered by the University of Bath, University of Birmingham, University of Bradford, Cardiff University, University of Hull, Imperial College London, University of Leeds, University of Nottingham, University of Oxford, Queen Mary University of London, University of Sheffield, University of Southampton, University of Surrey, and Swansea University. All these undergraduate courses are delivered on a full-time basis, both 3 year BEng and 4 year MEng degrees. Half of the 14 degree courses share a core first 2 years with a mechanical engineering stream. The other seven programmes include medical engineering modules earlier in their degrees. Within the courses, a very wide range of medical-engineering-related modules are offered, although more common modules include biomaterials, biomechanics, and anatomy and physiology.

Person-centred planning: factors associated with successful outcomes for people with intellectual disabilities

BACKGROUND

Recent research in the USA and UK indicates that person-centred planning (PCP) can lead to improvements in lifestyle-related outcomes for people with intellectual disabilities (ID). It is clear, however, that the introduction of PCP does not have an equal impact for all participants. The aim of the present paper was to identify factors associated with the probability of delivering a plan and with improvements in outcomes for those who did receive a plan.

METHODS

Information on the life experiences of participants was collected over a period of approximately 2 years for a cohort of 93 adults with ID.

RESULTS

There were powerful inequalities in both access to and the efficacy of PCP in relation to participant characteristics, contextual factors and elements of the PCP process.

CONCLUSIONS

Results are discussed in relation to implications for policy and practice for increasing the effectiveness of PCP and reducing inequalities in the life experiences of people with ID.

Tribologische Untersuchungen einer metakarpophalangealen Prothese

It is the goal of this paper to introduce modern tribological investigations into the development of a new finger prosthesis, with the particular aim of optimising the material component.A new, unconstrained metacarpophalangeal prosthesis restoring the anatomy of the joint has been developed in two versions (UHMWPE-metal and PEEK-metal). In order to determine the version having better wear behaviour, these two versions were tested on a Joyce finger simulator. As the UHMWPE-metal version showed a lower amount of wear in vitro, this version was chosen to conduct a clinical study. This investigation showed the importance of conducting an in vitro wear test before any clinical studies. Such tests allow the optimisation of the wear behaviour of the tested metacarpophalangeal prosthesis and therefore permit a minimisation of the possible risks to the patients.

Welfare reform and the perinatal health and health care use of Latino women in California, New York City, and Texas

OBJECTIVES

This study analyzed changes in the financing of prenatal care and delivery, the use of prenatal care, and birth outcomes among foreign-born vs US-born Latino women following enactment of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in August 1996.

METHODS

We used a pre-post design with a comparison group. The sample consisted of resident Latinas in California, New York City, and Texas who delivered a live infant in 1995 or 1998.

RESULTS

The proportion of births to Latinas that initiated prenatal care in the first 4 months of pregnancy increased for all foreign-born Latinas in California, New York City, and Texas between 1995 and 1998 (P <.05). Except for non-Dominicans in New York City, there was no increase in the proportion of low- or very-low-birthweight births among foreign-born vs US-born Latinas in the 3 localities between 1995 and 1996.

CONCLUSIONS

There is little evidence from vital statistics in California, New York City, and Texas that PRWORA had any substantive impact on the perinatal health and health care utilization of foreign-born relative to US-born Latinas.

Solar disinfection of drinking water protects against cholera in children under 6 years of age

BACKGROUND AND AIMS

We have previously reported a reduction in risk of diarrhoeal disease in children who used solar disinfected drinking water. A cholera epidemic, occurring in an area of Kenya in which a controlled trial of solar disinfection and diarrhoeal disease in children aged under 6 had recently finished, offered an opportunity to examine the protection offered by solar disinfection against cholera.

METHODS

In the original trial, all children aged under 6 in a Maasai community were randomised by household: in the solar disinfection arm, children drank water disinfected by leaving it on the roof in a clear plastic bottle, while controls drank water kept indoors. We revisited all households which had participated in the original trial.

RESULTS

There were 131 households in the trial area, of which 67 had been randomised to solar disinfection (a further 19 households had migrated as a result of severe drought). There was no significant difference in the risk of cholera in adults or in older children in households randomised to solar disinfection; however, there were only three cases of cholera in the 155 children aged under 6 years drinking solar disinfected water compared with 20 of 144 controls.

CONCLUSIONS

Results confirm the usefulness of solar disinfection in reducing risk of water borne disease in children. Point of consumption solar disinfection can be done with minimal resources, which are readily available, and may be an important first line response to cholera outbreaks. Its potential in chorine resistant cholera merits further investigation.

Changes in prenatal care timing and low birth weight by race and socioeconomic status: implications for the Medicaid expansions for pregnant women

OBJECTIVE

To conduct the first national study that assesses whether the Medicaid expansions for pregnant women, legislated by Congress over a decade ago, met the policy objectives of improved access to care and birth outcomes for poor and near-poor women.

DATA SOURCES/STUDY SETTING

Data on 8.1 million births using the 1980, 1986, and 1993 National Natality Files. We use births from all areas of the United States except California, Texas, Washington, and upstate New York.

METHODS

We conduct a before and after analysis that compares obstetrical outcomes by race and socioeconomic status for the periods 1980-86 and 1986-93. We examine whether women of low socioeconomic status showed greater improvements in outcomes during the 1986-93 period compared to the 1980-86 period. We analyze two obstetrical outcomes: the rate of late initiation of prenatal care and the rate of low birth weight.

DATA COLLECTION

Natality data were aggregated to race, socioeconomic status, age, and parity groups.

RESULTS

During the 1986-93 period, rates of late initiation of prenatal care decreased by 6.0 to 7.8 percentage points beyond changes estimated for the 1980-86 period for both white and African American women of low socioeconomic status. For some white women of low socioeconomic status, the rate of low birth weight was reduced by 0.26 to 0.37 percentage points between 1986 and 1993 relative to the earlier period. Other white women of low socioeconomic status and all African American women of low socioeconomic status showed no relative improvement in the rate of low birth weight during the 1986-93 period.

CONCLUSIONS

The expansions in Medicaid lead to significant improvements in prenatal care utilization among women of low socioeconomic status. The emerging lesson from the Medicaid expansions, however, is that increased access to primary care is not adequate if the goal is to narrow the gap in newborn health between poor and nonpoor populations.

Challenging behaviour in community services

The implementation of community care in the UK has led to the requirement that services should be able to meet the needs of adults with intellectual disability (ID) and additional needs in terms of challenging behaviour. However, the extent to which people with challenging behaviour are present in the community and the extent to which community services can support them effectively still requires significant research. The present study examines the prevalence of challenging behaviour amongst adults with ID residing in three London boroughs and the issues which arise from service delivery to this client group. All service providers and general practitioners in the area were contacted and asked to identify any individuals with ID and challenging behaviour. All responses were screened, and then key staff were interviewed for information on a range of demographic factors and on the Checklist of Challenging Behaviour. The reliability of the instrument was also assessed. Four hundred and forty-eight individuals were identified from a total borough population of 670 000. There was consistency in the types of behaviour which were frequently identified across the three boroughs. There were significant levels of self-injury as well as a range of behaviours of the 'hard to engage' type. Most individuals had more then one challenging behaviour and some individuals with seriously aggressive behaviour used local community services. Twenty-five per cent of the sample lived at home with their families and 50% were in community residential services. The boroughs differed in their ability to manage those with challenging behaviour in that one borough had many more people placed out-of-borough. Significant numbers of individuals with challenging behaviour were living in the community. The range and number of behaviours suggest that staff need to be very skilled in supporting such individuals, and that effective planning and support are essential if people with challenging behaviour are to be maintained in community settings.

Medicaid eligibility and the incidence of ambulatory care sensitive hospitalizations for children

In this study we investigate the effect of Medicaid on children's health, as measured by the incidence of ambulatory care sensitive (ACS) hospitalizations in the USA. The use of ACS hospitalizations is a unique contribution of our study. ACS discharges are known to be sensitive to better primary care and greater medical intervention and are objective measures of children's health. The results of this analysis were mixed. We found relatively robust evidence that the Medicaid expansions decreased the incidence of ACS hospitalizations among children age 2-6 from very low-income areas. For other groups of children, our results were less consistent. There was some evidence, although not uniform, that the Medicaid expansions improved the health of children age 2-6 from what we refer to as near-poor areas, areas with a median family income between $25,000 and 30,000. For older children, age 7-9, we found little evidence that the Medicaid expansions improved their health.

Paroxysmal supraventricular tachycardia: outcome after ED care

The objective of this study was to investigate the outcome and rate of symptomatic recurrence of paroxysmal supraventricular tachycardia (PSVT) in an emergency department (ED) patient population, after ED management and disposition. A retrospective descriptive review of ED records and state death registry was performed. The study took place at a University hospital ED with 60,000 annual patient volume. The subjects were all patients presenting to the ED in PSVT from January 1993 to December 1996. One hundred eleven patients met entry criteria. The mean age was 53 years, 49% were men, and 51% were women. EMS was used by 47 (42%) patients. Ten of these patients who used the EMS system had an unstable event in the prehospital setting. Eleven patients had unstable events once in the ED. ED therapy given (with number of successes in parentheses) included: Adenosine 48 (41), vagal maneuvers 44 (22), calcium channel blockers 22 (14), beta-blockers 10 (4), and electrical cardioversion 5 (1). Twenty-six patients (23%) spontaneously converted to normal sinus rhythm (NSR). Seventy-nine (71%) patients were discharged from the ED. Mean age for this group was 49 years, and the mean ED stay for this group was 3.8 hours. Three patients (4%) in this group had a recurrence of their SVT after discharge. These patients all had recurrence within 24 hours, and none had an unstable event associated with their recurrence. Thirty-two (29%) patients were admitted to the hospital, with 3 (9%) going to a monitored floor, and 29 (91%) going to an intensive care unit. Mean age for this group was 65 years. Twenty-one of these 32 admitted patients (65%) required continued in-hospital therapy once admitted for their arrhythmia. Six of the 32 admitted patients (19%) had recurrent PSVT in the hospital, with 1 episode of instability. Recurrence of PSVT was more likely to occur among those admitted (P <.05), in older patients (P<.01), and in those with a history of cardiovascular disease (P <.01). No deaths were recorded in either group. Most patients with PSVT can be safely discharged from the ED after short-term observation if therapy produces prompt conversion to NSR. PSVT recurrence is relatively uncommon and usually occurs within 24 hours of ED presentation. PSVT recurrence occurs more often in the elderly and in those with established cardiac disease.

The stability of pregnancy intentions and pregnancy-related maternal behaviors

OBJECTIVES

Our objectives were to characterize the stability of pregnancy intention and to examine whether stability is associated with the timing of prenatal care initiation, smoking during pregnancy, and breastfeeding.

METHODS

We use a sample of women from the National Longitudinal Survey of Youth (NLSY) for whom information on pregnancy intention was collected both during pregnancy and after delivery. In bivariate analyses we compare outcomes and characteristics of women whose pregnancy intention changed between the prenatal and postpartum periods. With multivariate methods, we analyze the correlates of switching pregnancy intention as well as the association between switching and maternal behaviors.

RESULTS

Women whose pregnancy intention changes between the two assessments are similar in marital status and socioeconomic background to those who report both during pregnancy and after delivery that the pregnancy is unintended. Disagreement during pregnancy between the parents' pregnancy intentions is the most important predictor of instability in the mother's pregnancy intention. Effects of unintended pregnancy on the timing of initiation of prenatal care, smoking during pregnancy, and breastfeeding based on reports after delivery are smaller than those based on reports during pregnancy, although differences are not statistically significant. Adverse effects of unintended pregnancy are greater when pregnancies reported by the mother to be unintended at either assessment are combined into a single category for unintended pregnancy.

CONCLUSION

Unstable pregnancy intention may be a marker for adverse maternal behaviors related to infant health.

Mental health service use by elderly patients with bipolar disorder and unipolar major depression

Symptoms, functioning, and mental health service use were compared in older out-patients with bipolar disorder and unipolar depression. Bipolar outpatients (n = 37, mean age = 69.7) had higher total symptom severity and positive symptom scores, more impaired community-living skills, and earlier age at onset of illness than patients with unipolar depression (n = 85, mean age = 70.9). Bipolar elderly patients used almost four times the total amount of mental health services and were four times more likely to have had a psychiatric hospitalization over the previous 6 months. These findings underscore the need for effective services for elderly patients with bipolar disorder, who account for a minority of patients with affective disorders, but use a disproportionate amount of costly services.

Did recent expansions in Medicaid narrow socioeconomic differences in hospitalization rates of infants?

OBJECTIVE

To test whether socioeconomic differences in the ratio of infant hospitalizations to births, a proxy for infant hospitalization rates, and hospital lengths of stay for infants narrowed between 1988 and 1992: a period of large increases in the numbers of low-income infants enrolled in Medicaid.

RESEARCH DESIGN

Before and after comparison of socioeconomic differences in the ratio of infant hospitalizations to births (ie, infant hospitalization rates) and lengths of stay between 1988 and 1992. By use of ICD-9 codes, hospitalizations were categorized as mandatory or discretionary. The difference between the 2 is that discretionary hospitalizations are potentially avoidable with appropriate primary care. Difference-in-differences techniques were used to assess the differential change in the rates of hospitalizations and lengths of stay for infants from low-income, compared with high-income, zip codes.

SETTING AND PARTICIPANTS

Discharges of infants <2 years of age at 326 nonfederal, short-term, general, and other specialty hospitals in 8 states.

OUTCOME MEASURES

Ratios of discretionary and mandatory hospitalizations to births (ie, hospitalization rates) and hospital lengths of stay of infants <2 years of age.

RESULTS

Infants from the poorest zip codes had ratios of discretionary hospitalizations to births (discretionary hospitalization rate) that were 3.1% points higher than infants from the wealthiest zip codes and ratios of mandatory hospitalizations to births (mandatory hospitalization rates) that were 0.2% points higher. Poor versus nonpoor differences in lengths of stay were 0.3 and 1.9 days for discretionary and mandatory hospitalizations, respectively. No narrowing in the socioeconomic gradients about ratios of hospitalizations to births (ie, rates of hospitalization) or lengths of stay was observed.

CONCLUSIONS

Expansions in the Medicaid program from 1988 to 1992 did not result in a decrease in ratios of discretionary hospitalizations to births (ie, discretionary hospitalization rate) or hospital length of stay for infants from low-income areas.

The impact of Mississippi's mandatory delay law on the timing of abortion

CONTEXT

Mississippi mandates that a woman seeking an abortion must first receive, in person, information about the fetus and alternatives to abortion. She must then wait at least 24 hours before having an abortion. It is not clear how such mandatory delay requirements affect the timing during pregnancy at which abortion occurs.

METHODS

The data for analysis, from the Mississippi Department of Health, are 34,748 abortions obtained by residents in the six-year period surrounding the law's enactment in August 1992 (i.e., from August 1989 through July 1995). The records were stratified by location of the nearest provider, so abortions to women whose nearest provider is in-state comprised the "treatment group" (N = 28,975), while abortions to women whose nearest provider is in a neighboring state with no such law comprised the "control group" (N = 5,773). Probit regressions were used to assess effects on the likelihood of a second-trimester abortion, and ordinary least-squares regressions were used to determine effects on gestational age at the time of the abortion.

RESULTS

After enactment of the law, the proportion of second-trimester procedures increased by 53% (from 7.5% of abortions to 11.5%) among women whose closest provider is in-state, but it increased by only 8% (from 10.5% to 11.3%) among women whose closest provider is out-of-state. And although the overall abortion rate declined among women in the treatment group over the period (from 11.3 procedures per 1,000 women aged 15-44 to 9.9), the rate of second-trimester procedures increased among these women (from 0.8 per 1,000 women aged 15-44 to 1.1). The law was independently associated with delays in obtaining an abortion: Once the law went into effect and net of all covariates, the proportion of second-trimester abortions increased by nearly three percentage points more among women living closest to an in-state provider than among those living closest to an out-of-state provider. The law increased the mean gestational age of the fetus at the time of the procedure by approximately four days. Women who live closest to abortion providers in other states were relatively unaffected by the law.

CONCLUSIONS

The proportion of abortions performed later in pregnancy will probably increase if more states impose mandatory delay laws with in-person counseling requirements.

Persistence and desistance of oppositional defiant disorder in a community sample of children with ADHD

OBJECTIVE

To examine the developmental progression of comorbid oppositional defiant disorder (ODD) in a community sample of children with attention-deficit hyperactivity disorder (ADHD) with particular emphasis on persistence and desistance of ODD and the emergence of new cases of conduct disorder (CD).

METHOD

A sample of disruptive children was identified from a multiple-gate epidemiological screen and stratified into diagnostic subgroups on the basis of a structured interview. A comparison sample of nondisruptive children was also identified. Group comparisons were performed on demographic, descriptive, family history, and clinical characteristics. Changes in rates of ODD symptoms and diagnostic subgroup membership were assessed after a 4-year longitudinal interval. Predictors of diagnostic group persistence were tested.

RESULTS

Few differences distinguished diagnostic subgroups at baseline. Of the 43 children with baseline diagnoses of ADHD + ODD, only 1 (2.3%) was found to have developed CD at follow-up. Over time there was a 57% rate of ODD persistence and a 43% rate of ODD desistance. Negative parenting practices and mothers' psychiatric disorders predicted persistence of ODD.

CONCLUSIONS

There was little evidence to show that ODD acted as a precursor to CD. However, when CD was diagnosed at baseline it was always associated with or preceded by ODD (i.e., prodrome). For a subgroup of children with ADHD, comorbid ODD symptoms are relatively unstable and may represent transient developmental perturbations that have little prognostic significance. For a larger subgroup of children with ADHD, ODD symptoms persist into the adolescent years and are associated with adverse parenting practices.

Solar disinfection of water reduces diarrhoeal disease: an update

349 Maasai children younger than 6 years old were randomised by alternate household to drink water either left in plastic bottles exposed to sunlight on the roof of the house or kept indoors (control). The trial was run in Maasai by Maasai community elders. Children drinking solar disinfected water had a significantly lower risk of severe diarrhoeal disease over 8705 two weekly follow up visits; two week period prevalence was 48.8% compared with 58.1% in controls, corresponding to an attributable fraction of 16.0%. While this reduction is modest, it was sustained over a year in free living children. It confirms solar disinfection as effective in vivo as a free, low technology, point of consumption method of improving water quality. The continuing use of solar disinfection by the community underlines the value of community participation in research.

Impact of augmented prenatal care on birth outcomes of Medicaid recipients in New York City

I examine whether New York State's Prenatal Care Assistance Program (PCAP) is associated with greater use of prenatal services and improved birth outcomes. PCAP is New York State's augmented prenatal care initiative that became a part of the Medicaid program after expansion in income eligibility thresholds in January, 1990. Data are from the linkage of Medicaid administrative files with New York City birth certificates (N = 23,249). For women on cash assistance, I find PCAP is associated with a 20% increase in the likelihood of enrollment in WIC, an increase in mean birth weight of 35 g and a 1.3 percentage point drop in the rate of low birth weight. Associations between PCAP and improved birth outcomes for women on medical assistance are similar, but appear contaminated by selection bias. Reductions in newborn costs associated with PCAP participation are modest, between US$100-300 per recipient, and are insufficient to offset program expenditures.

Conserved elements containing NF-E2 and tandem GATA binding sites are required for erythroid-specific chromatin structure reorganization within the human beta-globin locus control region

Proper expression of the genes of the human beta-globin gene locus requires the associated locus control region (LCR). Structurally, the LCR is defined by the presence of four domains of erythroid-specific chromatin structure. These domains, which have been characterized as DNase I hypersensitive sites (HSs), comprise the active elements of the LCR. The major focus of this research is to define the cis -acting elements which are required for the formation of these domains of unique chromatin structure. Our previous investigations on the formation of LCR HS4 demonstrated that NF-E2 and tandem, inverted GATA binding sites are required for the formation of the native HS. Similarly arranged NF-E2 and tandem GATA sites are present within the core regions of the other human LCR HSs and are evolutionarily conserved. Using site-directed mutagenesis of human HSs 2 and 3 we have tested the hypothesis that these NF-E2 and GATA sites are common requirements for the formation of all LCR HSs. We find that mutation of these elements, and particularly the GATA elements, results in a decrease or complete loss of DNase I hypersensitivity. These data imply the presence of common structural elements within the core of each LCR HS which are required for erythroid-specific chromatin structure reorganization.

Is Medicaid pronatalist? The effect of eligibility expansions on abortions and births

CONTEXT

Income thresholds for Medicaid eligibility for pregnant women were raised in two phases between 1987 and 1991. During roughly the same period, the U.S. fertility rate rose and the abortion rate declined; changes were particularly marked among young women, raising the possibility that fertility increases were related to Medicaid expansions.

METHODS

Pooled time-series cross-section regressions were used to examine the effects of the Medicaid eligibility expansions in 15 states on rates of abortions and births among unmarried women aged 19-27 with 12 or fewer years of schooling. Abortion data came from the National Center for Health Statistics or state health departments and were aggregated by women's age, race, marital status and schooling; data on births were from national natality tapes.

RESULTS

The Medicaid expansions were associated with a 5% increase in the birthrate among white women, but did not influence the rate among black women. Overall, no effect on the abortion rate was evident, but in analyses restricted to a subsample of eight states with the most complete abortion data, the rate among white women showed a significant decline after the second phase of expansions.

CONCLUSIONS

Subsidized health care for low-income pregnant women in these 15 states may have encouraged white women to have more children than they would have without coverage.

The impact of Mississippi's mandatory delay law on abortions and births

CONTEXT

Beginning August 8, 1992, a woman in the state of Mississippi had to wait 24 hours after in-person receipt of state-mandated information regarding abortion and birth complications, fetal development, and alternatives to abortion before an abortion could be performed.

OBJECTIVE

To analyze the effect of the law on the abortion and birth rates of Mississippi residents.

DESIGN

A retrospective analysis of abortion and birth rates before and after the law in Mississippi as contrasted with abortion and birth rates in 2 comparison states, Georgia and South Carolina. Neither Georgia nor South Carolina enforced a mandatory delay law, but both states began enforcement of parental notification statutes during the study period.

PATIENTS

Female residents of reproductive age in Mississippi, Georgia, and South Carolina between 1989 and 1994.

MAIN OUTCOME MEASURES

We compared birth rates, abortion rates, the percentage of late abortions, and the percentage of abortions performed outside the state of residence for all women and then by age and race before and after August 1992 among women of Mississippi, Georgia, and South Carolina.

RESULTS

We found that rate ratios (RRs) of resident abortion rates (rate after law implementation/rate before law implementation) declined 12% more in Mississippi than in South Carolina (95% confidence interval [CI], 8%-15%) and 14% more in Mississippi than in Georgia (95% CI, 10%-17%) in the 12 months after the law went into effect. Rate ratios for white adults declined 22% more in Mississippi than in South Carolina (95% CI, 17%-27%) and 20% more in Mississippi than in Georgia (95% CI, 15%-25%). Changes among nonwhite adults and white teens were more modest but also statistically significant (P<.05). For all women, RRs of the percentage of abortions performed after 12 weeks' gestation increased 39% more in Mississippi than in either South Carolina or Georgia (P<.05); the increase in the percentage of abortions after 12 weeks' gestation was observed for white and non-white adults (P<.05). We also show that the percentage of abortions performed out of state increased 42% more among women in Mississippi relative to women in South Carolina after the law (95% CI, 34%-50%).

CONCLUSION

The timing of the decline in abortion rates in Mississippi, the lack of similar declines in comparison states, the rise in percentage of late abortions and abortions performed out of state and the apparent completeness of abortion reports suggest that Mississippi's mandatory delay statute was responsible for a decline in abortion rates and an increase in abortions performed later in pregnancy among residents of Mississippi. The effect of delay laws in other states will likely depend on whether statutes require 2 separate visits to the abortion provider (ie, clinics, hospitals, or physicians' offices where abortions are performed) and the availability of abortion services.

The hospital cost of congenital syphilis

OBJECTIVE

To determine the hospital cost of caring for newborn infants with congenital syphilis.

STUDY POPULATION

All live-born singleton neonates with birth weight greater than 500 gm at an inner-city municipal hospital in New York City in 1989.

METHODS

We compared the characteristics of 114 infants with case-compatible congenital syphilis with those of 2906 infants without syphilis. Cost estimates were based on New York State newborn diagnosis-related groups (DRG) reimbursements adjusted for length of stay, birth weight, preterm delivery, and selected maternal risk factors, including infection with the human immunodeficiency virus, cocaine use during pregnancy, and history of injected drug use.

RESULTS

For infants with congenital syphilis, the unadjusted mean cost ($11,031) and the median cost ($4961) were more than three times larger than those for infants without syphilis (p < 0.01). After adjustment, congenital syphilis was associated with an additional length of hospitalization of 7 1/2 days and an additional cost of $4690 (both p < 0.01) above mean study population values (7.13 days, $3473).

CONCLUSIONS

Based on the number of reported cases (1991 to 1994), the average annual national cost of treating infants with congenital syphilis is approximately $18.4 million (1995 dollars). This estimate provides a benchmark to assess the cost-effectiveness of strategies to prevent, diagnose, and treat the disease.

Solar disinfection of drinking water and diarrhoea in Maasai children: a controlled field trial

BACKGROUND

Solar radiation reduces the bacterial content of water, and may therefore offer a method for disinfection of drinking water that requires few resources and no expertise.

METHODS

We distributed plastic water bottles to 206 Maasai children aged 5-16 years whose drinking water was contaminated with faecal coliform bacteria. Children were instructed to fill the bottle with water and leave it in full sunlight on the roof of the hut (solar group), or to keep their filled bottles indoors in the shade (control group). A Maasai-speaking fieldworker who lived in the community interviewed the mother of each child once every 2 weeks for 12 weeks. Occurrence and severity of diarrhoea was recorded at each follow-up visit.

FINDINGS

Among the 108 children in households allocated solar treatment, diarrhoea was reported in 439 of the 2-week reporting periods during the 12-week trial (average 4.1 [SD 1.2] per child). By comparison, the 98 children in the control households reported diarrhoea during 444 2-week reporting periods (average 4.5 [1.2] per child). Diarrhoea severe enough to prevent performance of duties occurred during 186 reporting periods in the solar group and during 222 periods in the control group (average 1.7 [1.2] vs 2.3 [1.4]). After adjustment for age, solar treatment of drinking water was associated with a reduction in all diarrhoea episodes (odds ratio 0.66 [0.50-0.87]) and in episodes of severe diarrhoea (0.65 [0.50-0.86]).

INTERPRETATION

Our findings suggest that solar disinfection of water may significantly reduce morbidity in communities with no other means of disinfection of drinking water, because of lack of resources or in the event of a disaster.

State reproductive policies and adolescent pregnancy resolution: the case of parental involvement laws

State laws regulating abortion have increased markedly in the wake of recent Supreme Court decisions. We test whether laws that require minors to notify or obtain consent from a parent before receiving an abortion affect the likelihood that a pregnancy will be terminated. We use individual data on births and abortions from three southern states, South Carolina, Tennessee, and Virginia. We find that South Carolina's parent consent statute is associated with a decline of 10 percentage points in the probability of abortion among non-black minors of 16 years of age. We find no effect for any other age or racial group and conclude that the impact of parental involvement laws on the pregnancy resolution of minors is not large.

The effect of expansions in Medicaid income eligibility on abortion

In this paper we examine the effect of expansions in Medicaid income eligibility on abortion, using individual-level data from South Carolina, Tennessee, and Virginia. The results suggest that for unmarried nonblack women with less than a high school degree, expansions of income eligibility lowered the probability of abortion by two to five percentage points. Most of the impact of the Medicaid expansions on abortion occurred in the first round of expansions from approximately 45% of the federal poverty level to 100%. For black unmarried women with less than a high school degree, we generally find no effect of expansions in Medicaid income eligibility on abortion.

Prevalence of enteropathogens in stools of rural Maasai children under five years of age in the Maasailand region of the Kenyan Rift Valley

Stool samples were collected during August 1994 from seventy rural Maasai children under the age of five years who were living in the Maasailand region of the Kenyan Rift Valley. Microbiological analysis was carried out on these samples to identify which intestinal pathogens were present among the infant population of the Maasai. Of the samples studied 54% were pathogen positive. The most common pathogen isolated was Giardia lamblia which was detected in 31% of the samples. Other pathogens that were detected include: Entamoeba histolytica (23%), Enteropathogenic Escherichia coli (13%), Strongyloides stercoralis (4%), Blastocystis hominis (3%) and Cryptosporidium sp (3%). Although all samples were screened for Campylobacter and rotavirus, neither pathogen was detected. Water samples were taken from all the water sources in the study area and analysed microbiologically. Results showed that all the sources were contaminated with the faecal E. coli whose populations ranged from 14 CFU/100 ml to greater than 1800 CFU/100ml.

Glycine N-methyltransferase is a mediator of cytochrome P4501A1 gene expression

Cytochrome P4501A1, the isozyme most closely approximating aryl hydrocarbon hydroxylase activity under conditions of induction, is thought to be regulated by several trans-acting factors, including the 4S polycyclic aromatic hydrocarbon-binding protein; this protein has recently been identified as glycine N-methyltransferase (Raha et al. (1994) J. Biol. Chem. 269, 5750-5756). Previous studies had shown that partially purified liver preparations containing the 4S binding protein interacted with 5'-flanking regions of the cytochrome P4501A1 gene. Consequently, the ability of the 4S binding protein to serve as a mediator in the regulation of the cytochrome P4501A1 gene was investigated further. Introduction of an antisense 24-mer oligonucleotide to glycine N-methyltransferase cDNA into rat hepatoma H4IIE cells by lipofectin resulted in a 60% reduction in the benzo(a)pyrene-mediated induction of ethoxyresorufin-O-deethylase activity and protein over the sense and scrambled antisense oligonucleotide controls. In addition, the antisense oligonucleotide caused a marked reduction in the steady-state level of cytochrome P4501A1 mRNA; no such effect was observed with the sense oligonucleotide. Introduction of GNMT polyclonal antibodies into H4IIE cells by a streptolysin-O permeabilization technique markedly reduced both benzo(a)pyrene-binding and benzo(a)-pyrene-induced ethoxyresorufin-O-deethylase activities, but had no effect on 2,3,7,8-tetrachlorodibenzo-p-dioxin induction. Collectively, these findings suggest that, in addition to the Ah (dioxin) receptor, glycine N-methyltransferase appears to be both a polycyclic aromatic hydrocarbon-binding protein and a mediator of the induction of the cytochrome P4501A1 gene by polycyclic hydrocarbons such as benzo(a)pyrene.

The impact of prenatal exposure to cocaine on newborn costs and length of stay

OBJECTIVE

Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs.

DATA SOURCES AND STUDY SETTING

All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992.

STUDY DESIGN

A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection.

DATA COLLECTION/EXTRACTION METHODS

Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition.

PRINCIPAL FINDINGS

Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.

NF-E2 and GATA binding motifs are required for the formation of DNase I hypersensitive site 4 of the human beta-globin locus control region

The beta-like globin genes require the upstream locus control region (LCR) for proper expression. The active elements of the LCR coincide with strong erythroid-specific DNase I-hypersensitive sites (HSs). We have used 5' HS4 as a model to study the formation of these HSs. Previously, we identified a 101 bp element that is required for the formation of this HS. This element binds six proteins in vitro. We now report a mutational analysis of the HS4 HS-forming element (HSFE). This analysis indicates that binding sites for the hematopoietic transcription factors NF-E2 and GATA-1 are required for the formation of the characteristic chromatin structure of the HS following stable transfection into murine erythroleukemia cells. Similarly arranged NF-E2 and GATA binding sites are present in the other HSs of the human LCR, as well as in the homologous mouse and goat sequences and the chicken beta-globin enhancer. A combination of DNase I and micrococcal nuclease sensitivity assays indicates that the characteristic erythroid-specific hypersensitivity of HS4 to DNase I is the result of tissue-specific alterations in both nucleosome positioning and tertiary DNA structure.

The association between prenatal care and birth weight among women exposed to cocaine in New York City

OBJECTIVES

Although the association between antenatal cocaine use and adverse birth outcomes has been well documented, relatively little is known about interventions that may ameliorate these consequences. We therefore examined the relationship between prenatal care and birth weight among a population of prenatal cocaine users.

DESIGN

Population-based retrospective analysis.

PATIENTS

All single-gestation live births to white non-Hispanic, black non-Hispanic, and Hispanic residents of New York City who gave birth between 1988 and 1990 with a positive indication for cocaine recorded on birth certificates (N = 7923).

MAIN OUTCOME MEASURES

We contrasted mean birth weight and rates of low birth weight (< 2500 g) among cocaine users with one to three prenatal care visits, four or more visits, and unknown numbers of visits with users who reported no prenatal care. We used ordinary least squares and logistic regression to control for age, parity, smoking, alcohol, other drugs, weight gain, prepregnancy weight, employment, marital status, participation in the Supplemental Food Program for Women, Infants and Children, and method of finance.

MAIN RESULTS

Adjusted odds ratios of low birth weight for cocaine users with four prenatal care visits or more as compared with those who had none were 0.51 for blacks (95% confidence interval [CI], 0.44 to 0.59), 0.39 for whites (95% CI, 0.23 to 0.66), and 0.37 for Hispanics (95% CI, 0.28 to 0.48). Adjusted mean birth weight differences between users with four visits or more and those with none were 262 g for blacks (P < .001), 247 g for whites (P < .001), and 317 g for Hispanics (P < .001).

CONCLUSIONS

The receipt of prenatal care among cocaine users is associated with significant improvements in birth weight. Enrollment of cocaine users in prenatal care may be an effective start to a more comprehensive approach to this problem.

Metabolism of chlorinated guaiacols by a guaiacol-degrading Acinetobacter junii strain

The metabolism of chlorinated guaiacols by a pure bacterial strain identified by its ability to use guaiacol as the sole carbon and energy source was studied. This strain, identified as Acinetobacter junii 5ga, was unable to grow on several chlorinated guaiacols and catechols. However, strain 5ga grown on guaiacol degraded 4- and 5-chloroguaiacol and 4,5-dichloroguaiacol. Under the same conditions, these cells did not degrade 6-chloroguaiacol, 4,6-dichloroguaiacol, 4,5,6-trichloroguaiacol, or tetrachloroguaiacol, suggesting that the substitution at the 6 position in the ring prevents metabolism of the compound. Degradation of 4-chloroguaiacol was dependent on the initial ratio between the chlorinated compound and viable cells. Transient formation of chlorocatechols resulting from incubation of cells with 4-chloroguaiacol or 4,5-dichloroguaiacol was suggested by UV spectroscopy. Gas chromatography analyses of samples from cultures of strain 5ga grown on guaiacol and incubated with 4- and 4,5-dichloroguaiacol confirmed the presence of 4-chlorocatechol and 4,5-dichlorocatechol, respectively. The formation of the latter was corroborated by gas chromatography-mass spectrometry. Thus, this strain is able to initiate metabolism of specific chlorinated guaiacols by O-demethylation. The starting chlorinated guaiacols and their O-demethylated metabolites inhibited the growth of A. junii 5ga on guaiacol.

An update on New York City's dramatic increase in low birthweights

Monthly time-series data on rates of low birthweight and very low birthweight in New York City from 1963 to 1990 indicate that the dramatic increase, particularly among Blacks beginning in 1984, appears to have peaked in 1988. Based on vital statistics records, the rate of low birthweight for Blacks fell from 13.1% in 1988 to 12.1% in 1990. The rate of low birthweight among Whites and Hispanics has fallen slightly since 1988.