"There is power in the blood": a case discussing ethical issues of utility of resources.

The allocation of medical resources is often a great concern in the United States. This article discusses a case concerning utility of resources in a patient with a terminal disease. We assert that the goals of treatment tailored to an individual patient should be made at the bedside by a fiduciary (physician) in conjunction with the patient's preferences and values. There is great responsibility in making these decisions and it is critical that they be made at the bedside with the patient and family clearly aware of the goals of treatments and informed of treatment limitations.

Developing guidelines for smoking cessation interventions for pregnant adolescents.

More than 400,000 deaths a year in the United States are attributed to active and passive tobacco smoke exposure. Healthy People 2000 objectives target a reduction in the tobacco use of high-risk populations such as youth and pregnant women. This article describes guidelines for health professionals to address smoking cessation when working with pregnant adolescents and teen mothers who smoke.

PIP: This article examines essential components of smoking cessation and health promotion interventions for pregnant and parenting adolescents. It also describes guidelines for health care professionals to address smoking cessation when working with pregnant adolescents and teen mothers who smoke. Both pregnancy and tobacco use are increasing among adolescents in the US. Evidence clearly indicates that cigarette smoking among pregnant adolescents is even higher than the national rate. Such a habit among pregnant teenagers presents an immediate risk to the fetus, plus an extended risk for establishment of entrenched smoking patterns for the teen. Cessation of smoking during pregnancy can have a profound effect in reducing infant mortality. To this effect, it is suggested that health care practitioners can have a positive influence on the health of the mothers, infants and children by encouraging and supporting smoking cessation efforts in young mothers. The practitioner is in a special position to provide this counseling during health supervision visits. Overall, the guidelines for intervention presented in this article can be used for school-based clinics with pregnant students and can be implemented easily in private practices or hospital-based clinics.

Small head size is related to low Mini-Mental State Examination scores in a community sample of nondemented older adults.

The objective of this analysis was to determine the relationship, if any, of head size to performance on a cognitive screening test among elderly nondemented adults participating in a community-based survey. The study sample included 825 subjects (533 women, 292 men), age 70 to 95 years. Multivariate analyses, with adjustment for age and education, revealed that smaller head size was associated with low Mini-Mental State Examination (MMSE) scores (i.e., below the 10th percentile) in both men and women. For every 1-centimeter increment in head size, there was a corresponding reduction of approximately 20% in the probability of a low MMSE score.

An assessment of nicotine dependence among pregnant adolescents.

Studies have reported that between 28 and 62% of pregnant teenagers smoke (Cornelius, Taylor, Geva, & Day, 1995; Trollestrup, Frost, & Starzyk, 1992). Because smoking is prevalent among pregnant teenagers, the purpose of this research is to assess nicotine dependence in this high-risk group. This study analyzed baseline data from a sample of pregnant teen smokers who had volunteered to participate in a smoking cessation study (N = 94). Nicotine dependence was measured by adapting the Fagerstrom Tolerance Questionnaire (FTQ; Prokhorov, Pallonen, Fava, Ding, & Niaura, 1996), and by a 6-item withdrawal symptom scale. The overall FTQ score found among pregnant adolescents was 3.10 (SD = 2.3) compared to the mean overall FTQ score among vocational-technical students of 4.27 (SD = 2.2) (Prokhorov et al., 1996). Duration of smoking in years was significantly correlated with the overall FTQ score (r = 0.43, p < .01). Quantity of smoking, as measured by average number of cigarettes smoked, significantly correlated with overall FTQ scores (r = 0.67, p < .01). Lighter smokers were more likely to have previously attempted to quit, however, among the quit attempters, those who smoked 10+ cigarettes per day reported greater severity of withdrawal symptoms than those who smoked less per day. Prenatal education and smoking cessation programs for pregnant teenagers, and pregnant women in general, need to consider that nicotine dependence is an important issue. Early pregnancy may be an opportune time to intervene among pregnant smokers; incentives may be necessary to attract those women who are the heaviest smokers, and possibly the most dependent on nicotine.

PIP: This study assessed nicotine dependence among pregnant adolescent smokers in order to enhance the efficacy of smoking-cessation programs. This study analyzed baseline data from a sample of 94 pregnant teen smokers who had volunteered to participate in a smoking cessation study. Nicotine dependence was measured by adapting Fagerstrom Tolerance Questionnaire (FTQ), and by a 6-item withdrawal symptom scale. The overall FTQ score found among pregnant adolescents was 3.10 (SD = 2.3) compared to the mean overall FTQ score among vocational-technical students of 4.27 (SD = 2.2). Duration of smoking in years was significantly correlated with the overall FTQ score. Quantity of smoking, as measured by average number of cigarettes smoked, significantly correlated with overall FTQ scores. Lighter smokers were more likely to have previously attempted to quit. However, among the attempters to quit, those who smoked 10+ cigarettes per day reported greater severity of withdrawal symptoms than those who smoked fewer per day. Prenatal education and smoking cessation programs for pregnant teenagers, and pregnant women in general, need to consider that nicotine dependence is an important issue. Early pregnancy may be an opportune time to intervene among pregnant smokers; incentives may be necessary to attract those women who are heaviest smokers, and possibly the most dependent on nicotine.

A preliminary study of the use of peer support in smoking cessation programs for pregnant adolescents.

This article describes preliminary findings of an experimental, randomized, three-group, controlled design examining the effectiveness of a smoking cessation intervention for pregnant teens. The three groups are: Teen FreshStart with a buddy program (TFSB), a Teen FreshStart program (TFS) without peer support, and the Usual Care (UC) control group. Forty-six subjects completed the post-intervention assessment of smoking status. The TFSB group consistently achieved greater smoking cessation across all measures when compared to the subjects in the other two groups. These results indicate that the use of peer support may be an effective adjunct in smoking cessation programs for pregnant adolescents.

PIP: It is estimated that smoking is related to 419,000 deaths per year in the US, with smokers losing an average of 15 years off their life expectancy. Results from two national surveys of high school students indicate that the level of cigarette smoking by teenagers increased from 19% in 1993 to 25.7% in 1996. This paper describes a multicomponent smoking cessation intervention for adolescents. The literature on adolescent smoking suggests that peers influence individual adolescent smoking status. The intervention was of experimental, randomized, 3-group, controlled design involving 84 unmarried pregnant women aged 12-20 years recruited from local prenatal clinics and public schools. The women were 4-28 weeks pregnant, 63% Black, and 37% White. Participants were randomized to one of the following groups: Teen FreshStart with a buddy program (TFSB), a Teen FreshStart program (TFS) without peer support, and the Usual Care (UC) control group. The TFS program is a standardized cognitive behavioral group model developed by the American Cancer Society specifically for adolescents. 46 subjects completed both the baseline and post-intervention assessments of smoking status. The TFSB group consistently achieved greater smoking cessation across all measures when compared to the subjects in the other two groups. These results therefore suggest that the use of peer support may help yield successful results from smoking cessation programs targeted to pregnant adolescents.

Random versus volunteer selection for a community-based study.

BACKGROUND: Selection methods vary greatly in ease and cost-effectiveness. The effects of selection factors associated with subjects' recruitment into studies can introduce bias and seriously limit the generalizability of results. METHODS: For an epidemiologic study, we recruited an age-stratified random sample of 1,422 community-dwelling individuals aged 65+ years from the voter registration lists in a rural area of southwestern Pennsylvania. The first 1,366 of these were accrued through intensive recruitment efforts; the last 56 of them responded to a single mailing. To increase sample size for future risk factor analyses, we also recruited by direct advertisement a sample of 259 volunteers from the same area. The three groups were compared on selected baseline characteristics and subsequent mortality. RESULTS: The two subgroups of the random sample were not significantly different on any of the variables we examined. Compared to the random sample, in cross-sectional analyses, volunteers were significantly more likely to be women, more educated, and less likely to have used several health and human services. Volunteers also had higher cognitive test scores and Instrumental Activities of Daily Living (IADL) ability. Over 6-8 years (10,861 person-years) of follow-up, volunteers had significantly lower mortality rates than randomly selected subjects. CONCLUSIONS: Health-related studies with populations composed partly or entirely of volunteers should take potential volunteer bias into account when analyzing and interpreting data.

Bipolar cautery and internal thermal sclerostomy in a rabbit model.

Internal thermal sclerostomy (ITS) was performed unilaterally in 35 adult New Zealand rabbits using a pinpoint bipolar cautery probe and radio-frequency power supply, with the nonoperated eyes serving as controls. Standard trabeculectomy using a limbal-based flap was also performed on 10 additional rabbits, and served as a second bench mark for comparison with the ITS technique. Intraocular pressure (IOP) was measured in all eyes preoperatively and on postoperative days 2, 4, 6, and 8. A significant (P = .005) difference between the reduction in IOP in the ITS eyes and in the control eyes was found up to postoperative day 8; on that day the reduction in IOP was 5.2 mm Hg. IOP in the eyes undergoing standard trabeculectomy was significantly (P = .05) reduced up to postoperative day 2, and gradually decreased, to 2.5 mm Hg, on postoperative day 8. The greatest reduction in IOP (2.9 mm Hg) for these eyes also occurred on postoperative day 2. Complications of ITS included iris burn (23%), peripheral corneal edema (17%), and iritis (9%). No ruptured blebs, flat anterior chambers, hyphemas, or lens damage occurred. The potential advantages of the ITS procedure using the bipolar cautery probe include a decreased risk of cataract formation because of the curved probe design. The procedure is also technically simple to perform and requires only inexpensive and readily-available equipment.

A study of the optical micrometer, the coin gauge, and the diamond knife micrometer in diamond knife calibration.

Reproducible results in refractive keratectomy are greatly influenced by an accurate setting of the diamond knife blade length. In this study, we evaluated the accuracy and reproducibility of three existing techniques of blade calibration: the KOI coin gauge, the KOI diamond knife handle micrometer, and the Magnum optical micrometer. Serial blade length measurements of three similarly designed KOI diamond knives were made using each of the above calibration methods. The three knife handle micrometers had the largest measurement error (3.55%, 2.83%, 1.82%), and therefore the sole reliance of the handle micrometer for blade calibration was not recommended. The measurements made by the coin gauge on the three knives had measurement errors of 1.03%, 1.64%, and 1.46%. The optical micrometer achieved an accuracy of 0.005 mm and an interobserver precision of 0.009 mm. We prefer using the optical micrometer because the potential for parallax error is eliminated; it has a lower risk of blade damage; it is easier to use; and it also allows detection of defects in the footplates, the diamond knife, and of the wobbling blade, which may contribute to calibration error.

Effect of recipient lamellar keratectomy on corneal topography in penetrating keratoplasty.

Recipient tissue weakness is thought to be a cause of the high residual astigmatism that may follow penetrating keratoplasty (PK). In a rabbit model, we investigated the topographic effect of a controlled lamellar keratectomy (6 x 3 x 0.25 mm) on the recipient side following PK. Results from 10 animals indicate an overall flattening of 5 D along the axis of the keratectomy--i.e., the axis of recipient tissue weakness. Our results indicate that recipient corneal integrity may be a factor in corneal transplant topography.

Myofascial trigger points in persistent posttraumatic shoulder pain.

Persistent pain and disability after injuries to the shoulder sometimes create a difficult diagnostic and therapeutic problem. In many such cases, myofascial trigger points seem to cause symptoms. Three cases in which pain had persisted for eight to 33 months after injury illustrate the manifestations of posttraumatic myofascial trigger point disorders. Trigger points are located by finding discrete foci of tenderness in muscles. Trigger points may be palpably firmer than surrounding muscle, forming nodules; they may twitch in response to palpation and may refer pain to a specific area when stimulated. Failure to recognize the myofascial source of pain can lead to erroneous diagnoses of articular, neurologic, or emotional disorder. Current pathophysiologic theories about trigger points may explain the persistence and topographic spreading of pain after muscular injuries. Appropriate treatment of myofascial trigger points can relieve chronic pain and disability.

Institutional prescribing for the elderly: patterns of prescribing in a municipal hospital and a municipal nursing home.

The drugs prescribed for long-term use by 56 elderly patients while they were under domiciliary care in a municipal hospital were compared with the drugs prescribed for the same patients six months after they had moved to a city nursing home. All patients were at least 65 years old, and were in the hospital for at least six months. Mean numbers of prescriptions per patient were 4.1 in the hospital and 3.7 in the nursing home. Diuretics and potassium chloride were prescribed less often in the nursing home, but the number of patients taking digitalis glycosides increased. Use of tranquilizers and of sedatives and hypnotics was less in the nursing home, whereas a larger proportion of patients were given antidepressant drugs. In the hospital, tranquilizers and nonsteroidal antiinflammatory drugs were usually ordered to be administered routinely, while in the nursing home these drugs were ordered mostly for use as needed. Explanation of the differences between the two institutions in prescribing for the same patients is hindered by the frequent lack of recorded diagnoses accounting for the drugs prescribed in the hospital. The lesser use of tranquilizers in the nursing home may be a result of the difference between the environments there and at the hospital. In comparison with previous reports of institutional prescribing for the elderly, far fewer patients in both the institutions studied were receiving tranquilizers, sedatives, and hypnotics.

Gout and hyperuricemia associated with sickle-cell anemia.

Since the initial description, in 1958, of gouty arthritis occurring in association with SCA, more than 12 cases have been reported. The high proportion of women and the relatively young ages are noteworthy. Since 1968, studies of patients with SCA have shown a high prevalence of hyperuricemia, beginning during childhood. The initial event in the development of hyperuricemia presumably is increased synthesis of nucleic acids occurring as part of the erythropoietic response to hemolysis. Catabolism of the nucleic acids generates urate. Increased production of UA normally is compensated for by increased urinary excretion of UA. This response occurs in patients with SCA, but during the third decade of life hyperuricosuria can be reduced, probably by damage to the renal tubules caused by infarction and hypoxia resulting from sickling. Impairment of the compensatory renal response leads to more severe and sustained hyperuricemia, and gouty arthritis may then develop. A number of questions about hyperuricemia and gout in SCA remain unanswered. The prevalence of gout among patients with SCA, both in general and in relation to age and sex, has not been determined. The relationships between specific aspects of SCA and of hyperuricemia and gout need to be determined. These include any effect of sickle cell crises on SUA and attacks of gout, and correlation of abnormalities in renal handling of urate with other indices of tubular function and with the pathologic anatomy of the kidney. Finally, it is important to learn whether hyperuricemia and hyperuricosuria contribute to the renal manifestations of SCA; if so, allopurinol might be useful in the prevention and treatment of the renal disease.