C1-2 rotatory subluxation as a presenting sign in juvenile rheumatoid arthritis.

STUDY DESIGN: Case report. INTRODUCTION: Juvenile rheumatoid arthritis (JRA) typically presents with fever, rash, anterior uveitis, and/or joint pain. We present three cases with initial torticollis due to rotatory subluxation of C1-C2 as an initial sign of JRA. CASE REPORTS: Three girls, ages 5-9, presented with C1-2 rotatory subluxation. Traction was able to reduce the atlanto-axial joint in all cases. Based on imaging, history, exam, and laboratory results, they were diagnosed with JRA. After reduction of the atlantoaxial joint, they were transitioned to a halo vest and disease-modifying antirheumatic drugs (DMARDs). The older 2 children underwent C1-2 fusion. The younger child has minimal symptoms and has not undergone surgical intervention 4 years from initial presentation. CONCLUSION: Rotatory subluxation can be the first presenting sign of JRA. Younger children may be able to be treated conservatively with traction and medication, while older children may require occiput to C2 fusion due to bony destruction and basilar invagination. LEVEL OF EVIDENCE: IV.

Motivational interviewing to improve postabortion contraceptive uptake by young women: development and feasibility of a counseling intervention.

OBJECTIVE: The objective was to develop and test a postabortal contraception counseling intervention using motivational interviewing (MI) and to determine the feasibility, impact and patient acceptability of the intervention when integrated into an urban academic abortion clinic. STUDY DESIGN: A single-session postabortal contraception counseling intervention for young women aged 15-24 years incorporating principles, skills and style of MI was developed. Medical and social work professionals were trained to deliver the intervention, their competency was assessed, and the intervention was integrated into the clinical setting. Feasibility was determined by assessing ability to approach and recruit participants, ability to complete the full intervention without interruption and participant satisfaction with the counseling. RESULTS: We approached 90% of eligible patients and 71% agreed to participate (n=20). All participants received the full counseling intervention. The median duration of the intervention was 29 min. Immediately after the intervention and at the 1-month follow-up contact, 95% and 77% of participants reported that the session was helpful, respectively. CONCLUSIONS: MI counseling can be tailored to the abortion setting. It is feasible to train professionals to use MI principles, skills and style and to implement an MI-based contraception counseling intervention in an urban academic abortion clinic. The sessions are acceptable to participants. IMPLICATIONS: The use of motivational interviewing in contraception counseling may be an appropriate and effective strategy for increasing use of contraception after abortion. This study demonstrates that this patient-centered, directive and collaborative approach can be developed into a counseling intervention that can be integrated into an abortion clinic.

Orthodeoxia and postural orthostatic tachycardia in patients with pulmonary arteriovenous malformations: a prospective 8-year series.

Postural changes in 258 patients with pulmonary arteriovenous malformations (PAVMs) reviewed between 2005 and 2013 were evaluated prospectively using validated pulse oximetry methods. Of the 257 completing the test, 75 (29%) demonstrated orthodeoxia with an oxygen saturation fall of at least 2% on standing. None described platypnoea (dyspnoea on standing). The heart rate was consistently higher in the erect posture: 74 (29%) had a postural orthostatic tachycardia of ≥20 min(-1), and in 25 (10%) this exceeded 30 min(-1). Orthostatic tachycardia was more pronounced in PAVM patients than controls without orthodeoxia (age-adjusted coefficient 5.5 (95% CIs 2.6, 8.4) min(-1), p<0.001). For PAVM patients, the age-adjusted pulse rise was 0.79 min(-1) greater for every 1% greater drop in oxygen saturation on standing (p<0.001). In contrast to the postural orthostatic tachycardia syndrome, in this population, there was a trend for more pronounced orthostatic tachycardia to be associated with better exercise tolerance.

Physiological determinants of climbing-specific finger endurance and sport rock climbing performance.

The aim of the study was to examine several physiological responses to a climbing-specific task to identify determinants of endurance in sport rock climbing. Finger strength and endurance of intermediate rock climbers (n = 11) and non-climbers (n = 9) were compared using climbing-specific apparatus. After maximum voluntary contraction (MVC) trials, two isometric endurance tests were performed at 40% (s = 2.5%) MVC until volitional exhaustion (continuous contractions and intermittent contractions of 10 s, with 3 s rest between contractions). Changes in muscle blood oxygenation and muscle blood volume were recorded in the flexor digitorum superficialis using near infra-red spectroscopy. Statistical significance was set at P < 0.05. Climbers had a higher mean MVC (climbers: 485 N, s = 65; non-climbers 375 N, s = 91) (P = 0.009). The group mean endurance test times were similar. The force-time integral, used as a measure of climbing-specific endurance, was greater for climbers in the intermittent test (climbers: 51,769 N x s, s = 12,229; non-climbers: 35,325 N x s, s = 9724) but not in the continuous test (climbers: 21,043 N x s, s = 4474; non-climbers: 15,816 N x s, s = 6263). Recovery of forearm oxygenation during rest phases (intermittent test) explained 41.1% of the variability in the force-time integral. Change in total haemoglobin was significantly greater in non-climbers (continuous test) than climbers (P = 0.023--40% test timepoint, P = 0.014--60% test timepoint). Pressor responses were similar between groups and not related to the force-time integral for either test. We conclude that muscle re-oxygenation during rest phases is a predictor of endurance performance.

Responses of Tuatara (Sphenodon punctatus) to removal of introduced Pacific rats from islands.

Invasive mammalian predators such as rats are now widespread on islands, but hypotheses about their effects have rarely been tested. Circumstantial evidence from New Zealand indicates that, when introduced to islands, Pacific rats (Rattus exulans) have negative effects on endemic plants, invertebrates, birds, and reptiles, including the tuatara (Sphenodon punctatus). We tested the effects of Pacific rats on tuatara by comparing the demographic structure and body condition of tuatara populations on three islands before and after removal of rats and on a fourth island where rats remained. In the presence of rats, juvenile tuatara constituted on average 0-5% of the sample tuatara populations. When Pacific rats were removed after at least 200 years' occupancy, the proportion of juvenile tuatara increased 3.5- to 17-fold and body condition of adult males and females also improved (sometimes dramatically). We predict that, unless Pacific rats are removed from Taranga Island, the tuatara population will collapse because of low population density and the lack of juvenile recruitment. Our results demonstrate that when invasive species exert subtle effects on recruitment and body condition, the effects on populations of long-lived endemic species may only become apparent long after the invasion.

Climbing-specific finger endurance: a comparative study of intermediate rock climbers, rowers and aerobically trained individuals.

The aim of this study was to compare the climbing-specific finger endurance of climbers, rowers and aerobically leg trained athletes. Twenty-seven males aged 21.2 +/- 2.2 years (mean +/- s) volunteered for the study. The participants were intermediate rock climbers (n = 9), rowers (n = 9) and leg trained athletes (n = 9). Maximal voluntary contraction (MVC) was determined on climbing-specific finger apparatus. Endurance isometric exercise was performed at 40% MVC in three tests performed in a random order: (1) sustained exercise; (2) 6 s exercise, 4 s rest; and (3) 18 s exercise, 12 s rest. Pre- and post-exercise blood pressure and blood lactate concentration, together with post-exercise pain perception, were measured. The climbers had a significantly greater MVC (383 +/- 35.6 N) than the rowers (321 +/- 49.5 N, P = 0.007) and aerobically leg trained athletes (288 +/- 60.6 N, P = 0.001). There were no significant differences between the groups in terms of endurance times for any of the tests. In the test with 18 s exercise and 12 s rest, the climbers showed a significantly higher increase in blood lactate concentration, on average, than the rowers by 0.01-0.89 mmol x l(-1) (P = 0.006); there were no significant differences, on average, in the comparisons of climbers and the leg trained athletes and rowers and the leg trained athletes. There were no significant differences in the average changes in blood pressure from rest to post-exercise between any of the groups. Although the climbers had greater MVC on average than the other two groups, there were no significant differences in average endurance times amongthe groups. These findings suggest that training for rock climbing and participation in rock climbing may result in some specific adaptations. However, we acknowledge that this study is descriptive and there is the possibility that differences between groups could be attributed to self-selection.

Behavioural problems in children who weigh 1000 g or less at birth in four countries.

BACKGROUND: The increased survival chances of extremely low-birthweight (ELBW) infants (weighing <1000 g at birth) has led to concern about their behavioural outcome in childhood. In reports from several countries with different assessments at various ages, investigators have noted a higher frequency of behavioural problems in such infants, but cross-cultural comparisons are lacking. Our aim was to compare behavioural problems in ELBW children of similar ages from four countries. METHODS: We prospectively studied 408 ELBW children aged 8-10 years, whose parents completed the child behaviour checklist. The children came from the Netherlands, Germany, Canada, and USA. The checklist provides a total problem score consisting of eight narrow-band scales. Of these, two (aggressive and delinquent behaviour) give a broad-band externalising score, three (anxious, somatic, and withdrawn behaviour) give a broad-band internalising score, and three (social, thought, and attention problems) indicate difficulties fitting neither broad-band dimension. For each cohort we analysed scores in ELBW children and those in normal- birthweight controls (two cohorts) or national normative controls (two cohorts). Across countries, we assessed deviations of the ELBW children from normative or control groups. FINDINGS: ELBW children had higher total problem scores than normative or control children, but this increase was only significant in European countries. Narrow-band scores were raised only for the social, thought, and attention difficulty scales, which were 0.5-1.2 SD higher in ELBW children than in others. Except for the increase in internalising scores recorded for one cohort, ELBW children did not differ from normative or control children on internalising or externalising scales. INTERPRETATION: Despite cultural differences, types of behavioural problems seen in ELBW children were very similar in the four countries. This finding suggests that biological mechanisms contribute to behavioural problems of ELBW children.

Textilinins from Pseudonaja textilis textilis. Characterization of two plasmin inhibitors that reduce bleeding in an animal model.

The incidence of vein-graft occlusion associated with myocardial infarction and thrombosis following the use of the plasmin inhibitor, aprotinin, to reduce blood loss during vascular surgery has prompted the isolation of an alternative kinetically distinct inhibitor of plasmin from the venom of Pseudonaja textilis. This inhibitor has been called textilinin (Txln) and two distinct forms have been isolated from the Brown-snake venom (molecular weight, 6688 and 6692). A comparison of plasmin inhibitor constants for aprotinin and the Txlns 1 and 2 indicated that the former bound very tightly (inhibitor constant, Ki approximately 10(-11) mol/l), while both of the latter bound less tightly (Ki approximately 10(-9) mol/l). Homogeneity of Txlns 1 and 2 was confirmed by sodium dodecyl sulphate-polyacrylamide gel electrophoresis and mass spectrometry. A sequence difference of six amino acids was observed between the two forms of Txln. Txln 1 and 2 showed, respectively, 45 and 43% homology with aprotinin, while there was 58 and 55% homology, respectively, with a plasmin inhibitor from the venom of eastern Taipan, Oxyuranus scutellatus. Both Txlns have six cysteines, like other inhibitors of this group, and homology was determined by alignment of these cysteines. Both have been shown to reduce blood loss by about 60% in a murine tail vein bleeding model. It is proposed that the kinetic profiles of Txln 1 and 2 for plasmin allow the arrest of haemorrhage without the possible threat of thrombosis.

Binocular summation in the fovea and peripheral field of anisometropic amblyopes.

PURPOSE: Binocular performance in the central and peripheral visual fields was compared for normal and anisometropic amblyopes. METHODS: Binocular and monocular thresholds to a light detection task were measured along the four principal meridia in 10 young normal subjects and 10 anisometropic amblyopes using the Humphrey's Visual Field Analyser. Thresholds were obtained at the fovea and at retinal eccentricities of 5 masculine, 10 masculine, 15 masculine, 25 masculine, 40 masculine and 55 masculine on the horizontal, vertical and oblique meridia of 45 masculine and 135 masculine. RESULTS: Binocular summation ratios (binocular sensitivity/ 'best' monocular sensitivity) were calculated for all the eccentricities. In the normal group, the mean binocular summation ratio for the fovea and the peripheral field was not significantly different. In the amblyopic group, subjects showed no or minimal binocular summation in the foveal region but reached normal ratios in the periphery. DISCUSSION: Results are discussed in terms of tolerance to interocular sensitivity differences in the periphery and selective losses in cortical cells.

Relation of cranial ultrasound abnormalities in low-birthweight infants to motor or cognitive performance at ages 2, 6, and 9 years.

This study sought to determine whether neonatal cranial ultrasound abnormalities are related to motor and cognitive outcomes in low-birthweight (LBW, <2000 g) children without major motor or cognitive disability. The relation of neonatal cranial ultrasound abnormalities to motor performance and general cognitive ability at ages 2, 6, and 9 years was examined in a prospectively followed regional cohort of LBW children, excluding those with major disability, and controlling for other risk factors. Compared with children without ultrasound abnormalities, children with abnormalities indicative of ischemic white-matter injury had poorer motor performance at all three ages and, at age 2, lower general cognitive ability. The latter finding was not seen when motor performance was also controlled for. It was concluded that in LBW children without major motor or cognitive disability, ischemic white-matter injury indicated by neonatal cranial ultrasound abnormalities adversely affected motor performance at ages 2, 6, and 9 years, but not general cognitive ability.

Focused antithrombotic therapy: novel anti-platelet salicylates with reduced ulcerogenic potential and higher first-pass detoxification than aspirin in rats.

The use of aspirin as an anti-platelet drug is limited by its propensity to induce gastric injury and by its adverse effect on vascular prostacyclin formation. Two phenolic non-steroidal anti-inflammatory drugs (salicylic acid and diflunisal) were modified by esterification with a series of O-acyl moieties. The short-term ulcerogenic in vitro and in vivo anti-platelet properties, pharmacodynamic profiles, and extent of hepatic extraction of these phenolic esters were compared with aspirin (acetylsalicylic acid). The more lipophilic esters (longer carbon chain length in O-acyl group) show significantly less gastrotoxicity in stressed rats than does aspirin after a single oral dose. The in vitro and in vivo anti-platelet studies show that these phenolic esters inhibited (1) arachidonate-triggered human platelet aggregation and (2) thrombin-stimulated rat serum thromboxane A2 production by platelets in the clotting process almost as effectively as aspirin. The hepatic extractions of these O-acyl derivatives are significantly higher than those of aspirin. The pharmacodynamic studies show that these O-acyl derivatives of salicylic acid and diflunisal probably bind to, or combine with, the same site on the platelet cyclooxygenase as aspirin. Replacing the O-acetyl group with longer chain O-acyl moiety in this series of phenolic esters markedly reduced the potential of these agents to induce short-term gastric injury but did not lessen their activity as inhibitors of platelet aggregation. These non-acetyl salicylates may therefore represent a novel class of anti-platelet drugs with less ulcerogenic potential.

Randomised trial of effectiveness of second eye cataract surgery.

BACKGROUND: The effectiveness of cataract surgery on one eye is well established, but concerns over health-care expenditure have called into question the value of cataract surgery on the second eye. We examined the effects of second eye surgery in terms of patient perceptions as well as through visual acuity, contrast sensitivity, and stereoacuity tests. METHODS: 208 otherwise healthy patients awaiting second eye cataract surgery were recruited into our randomised trial. At randomisation participants were allocated expedited surgery (planned to take place within 6 weeks) or routine surgery (routine waiting time, 7-12 months). Assessments were made at randomisation and again at review after about 6 months. Eight primary trial outcomes consisted of four questionnaire items and four visual function tests, done with both eyes open. FINDINGS: Traditional clinical tests of success in cataract surgery (visual acuity and contrast sensitivity) showed only slight differences in binocular vision in favour of the expedited-surgery group. There were major benefits for the expedited-surgery group in terms of reported visual symptoms and effects on quality of life. At review, differences in self-reported vision related difficulties between the two groups ranged from 11% (95% CI 4.4-17%, activities) to 30% (19-41%, reading). Stereoacuity was better in the expedited surgery group, the difference between the groups for the proportions with stereoacuity of 3000 s of arc or worse was 58% (47-69%). INTERPRETATION: This trial has shown that there is a clear benefit from second eye cataract surgery.

Brown snakes (Pseudonaja genus): venom yields, prothrombin activator neutralization and implications affecting antivenom usage.

The recent high prevalence of fatal bites by Brown snakes (Pseudonaja genus) has led to this study of venom yields from 66 brown snake milkings over 15 months. The amount of venom obtained from all species was higher than reported previously. Electrophoretic and Western blotting analyses of their venoms showed significantly lower avidity of Brown snake antivenom (BS-AV) for the prothrombin activator (PA) component (190 kD) than for other venom components, including the neurotoxins. The LD50 of P. inframacula has been determined for the first time. SDS-PAGE (sodium dodecyl sulphate-polyacrylamide gel electrophoresis) and Western blotting studies have shown that the Pseudonaja venoms contained proportionately more PA component than venoms of the Taipan (Oxyuranus scutellatus) or the Fierce snake (O. microlepidotus). Neutralization of the prothrombin activator of the Common Brown snake (P. textilis) (Pt-PA) by BS-AV was found to be time dependent and 40% remained unneutralized after 30 minutes incubation. Adult rats administered quantities of Pt-PA (IV) died with acute disseminated intravascular coagulation. Rats were made resistant to Pt-PA by preheparinization or by induction of tolerance to increasing quantities of Pt-PA. There is no evidence that Pt-PA has intrinsic toxicity apart from being a procoagulant. The improvement of BS-AV by addressing its deficiencies should be canvassed.

Psychiatric outcomes in low-birth-weight children at age 6 years: relation to neonatal cranial ultrasound abnormalities.

BACKGROUND: This study examined the relation of neonatal cranial ultrasound abnormalities to psychiatric disorder at age 6 years in a regional birth cohort of low-birth-weight children. METHODS: Neonatal cranial ultrasound abnormalities were classified as (1) isolated germinal matrix and/or intraventricular hemorrhage (suggestive of injury to glial precursors) or (2) parenchymal lesions and/or ventricular enlargement (suggestive of white matter injury) with or without germinal matrix-intraventricular hemorrhage. Psychiatric disorders by DSM-III-R at age 6 years were assessed by means of a structured parent interview. Children with severe mental retardation were excluded. Analyses were conducted first in the entire sample and then in children with normal intelligence. RESULTS: Twenty-two percent of the cohort had at least 1 psychiatric disorder, the most common being attention deficit hyperactivity disorder (15.6%). In the entire sample, parenchymal lesions and/or ventricular enlargement increased risk relative to no abnormality, independently of other biological and social predictors, for any disorder (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.8-10.3; P < .001), attention deficit hyperactivity disorder (OR, 3.4; CI, 1.3-8.7; P = .02), and tic disorders (OR, 8.7; CI, 1.3-57.7; P = .02). In children of normal intelligence, parenchymal lesions/ventricular enlargement independently increased risk for any disorder (OR, 4.8; CI, 1.6-12.0; P < .01), attention deficit hyperactivity disorder (OR, 4.5; CI, 1.3-16.0; P = .02), and separation anxiety (OR, 5.3; CI, 1.1-24.8; P = .03). These effects were not ameliorated by female sex or social advantage. Isolated germinal matrix/intraventricular hemorrhage was not related to psychiatric disorder at age 6 years. CONCLUSION: Neonatal cranial ultrasound abnormalities suggestive of white matter injury significantly increased risk for some psychiatric disorders at age 6 years in low-birth-weight children.

Trans-tracheal ventilation complicated by bilateral pneumothoraces and pneumoperitoneum.

Following induction of general anaesthesia for emergency caesarean section the trachea could not be intubated, and ventilation was established only following two cricothyroidotomies. The baby was delivered unimpaired, and tracheostomy subsequently performed. On the intensive care unit, maternal cardiorespiratory variables were satisfactory, although surgical emphysema of the face and neck became apparent. Increasing abdominal distension was relieved by suction to a pelvic drain. Radiographs revealed bilateral pneumothoraces, pneumomediastinum and pneumoperitoneum, which were resolved by intrapleural drainage.

Risperidone in adolescents with schizophrenia: an open pilot study.

OBJECTIVE: To assess critically the short-term efficacy and safety of risperidone in adolescents with schizophrenia. METHOD: Subjects were adolescents who were attending a research day hospital as outpatients and who had received a diagnosis of schizophrenia. This was an open pilot study; after a 2-week washout period during which all psychotropic medications were gradually discontinued, subjects were treated with risperidone for 6 weeks. Dosage was regulated individually over a period of 3 weeks; starting dose was 2.0 mg/day followed by 1.0-mg increments every 2 days; maximum dose was not to exceed 10 mg/day. The main outcome measures included the Positive and Negative Syndrome Scale of Schizophrenia, the Brief Psychiatric Rating Scale, and the Clinical Global Impression. RESULTS: Ten adolescents between 11 and 18 years of age were enrolled in the study. Risperidone produced clinically and statistically significant improvement on the Positive and Negative Syndrome Scale for Schizophrenia. Brief Psychiatric Rating Scale, and Clinical Global Impression at doses ranging from 4.0 mg/day to 10.0 mg/day (mean = 6.6). There were no major adverse reactions associated with risperidone use. CONCLUSIONS: Risperidone appears to have been effective and well tolerated in this sample of adolescents with schizophrenia.

Hypercoagulability and hypofibrinolysis in primary osteoarthritis.

Histologic evidence of venous thrombosis and lipid abnormalities have previously been reported in osteoarthritis. Hypofibrinolysis has been recorded in patients with ischemic necrosis of bone, and it has been proposed as a major cause of osteonecrosis. This study determines whether systemic evidence of coagulation and lipid abnormalities could be detected in osteoarthritis. Global and specific tests were used to assess coagulability and fibrinolysis in 44 patients with degenerative osteoarthritis of the hip and 52 matched control subjects. In patients with osteoarthritis, an increase in factor VIIlc, increased platelet sensitivity over a range of adenosine diphosphate concentrations (0.05 micromol/L-4 micromol/L) and elevated D dimer levels were found. Euglobulin clot lysis time was prolonged in this group and plasminogen activator inhibitor Type 1 activity was increased. Relative hyperlipidemia was observed in the osteoarthritis group, with increased cholesterol, low density lipoprotein cholesterol, and triglyceride levels. It is concluded that there is a hypercoagulable and prothrombotic condition in osteoarthritis, with hypofibrinolysis and indirect evidence of increased fibrin generation. The possible contribution of lipid abnormalities to hemostatic imbalance in osteoarthritis is discussed.

The one-stop coronary cholesterol clinic: a multidisciplinary approach to implementing evidence-based treatment.

We describe a 'one-stop' cholesterol clinic implementing a regime based on the Scandinavian Simvastatin Survival Study (4S) in patients with established coronary heart disease in a district general hospital. The clinic has been established in collaboration with the cardiac rehabilitation centre. It was commissioned as an audit project by the purchasing authority, Walsall Health, a need having been shown in a previous audit. In the new clinic, audit is inbuilt, rather than being carried out as a separate retrospective exercise, and undertaken prospectively for all patients. Central to this is a database, used for routine correspondence and administration, as well as monitoring outcome. This application of information technology has improved clinical practice. Attendance at the clinic has been excellent. Half the consultations have resulted in therapeutic interventions, many of which may otherwise have been missed. Over 50% of patients were eligible for lipid-lowering medication under the protocol. Cholesterol targets based on 4S were achieved but with much lower drug doses, which may have major cost implications. Cholesterol levels measured within 24 hours of admission for myocardial infarction were poor predictors of results obtained after convalescence. After the clinic visit, most patients were taking aspirin plus one or two other secondary prevention treatments. Guidelines have been issued to primary care. Future plans for audit links with general practitioners, integration of the metabolic and cardiological assessment of survivors of myocardial infarction, and for long-term monitoring of clinical events in treated patients are discussed.

Neonatal cranial ultrasound abnormalities in low birth weight infants: relation to cognitive outcomes at six years of age.

OBJECTIVE: To assess the independent relation of neonatal cranial ultrasound (US) abnormalities in low birth weight (LBW) infants to cognitive outcomes at 6 years of age. DESIGN: Prospective cohort study. SAMPLE AND METHODS: Six-year follow-up data were obtained on a regional birth cohort of LBW infants (< 2 kg) systematically screened as neonates with serial US. US abnormalities were dichotomized into isolated germinal matrix/intraventricular hemorrhage (GM/IVH) and parenchymal lesions/ventricular enlargement (PL/VE). Global cognitive outcomes (mental retardation, borderline intelligence, and normal intelligence) and selected specific cognitive abilities were assessed at 6 years of age with standardized instruments. Multivariate techniques were used to assess the effects of US independent of maternal social disadvantage at birth and other perinatal and neonatal risk factors. RESULTS: The sample as a whole had a significantly elevated rate of mental retardation (MR; 5%), almost all moderate to profound in severity. PL/VE was independently related to MR (odds ratio [OR], 65.8; confidence interval [CI], 19.1 to 22.4) and borderline intelligence (OR, 3.7; CI, 1.3 to 10.8); isolated GM/IVH was more modestly related to MR (OR, 4.6; CI, 1.2 to 18.6) but not related to borderline intelligence. Approximately half of the cases of MR were attributable to PL/VE independent of other factors. Of non-US factors, the number of days receiving mechanical ventilation increased the risk for MR. Maternal social disadvantage increased the risk for borderline intelligence but not MR. Among children of normal intelligence, those with PL/VE, but not isolated GM/IVH, performed more poorly than those without US abnormalities on tests of visual perceptual organization but not on tests of language, memory, or quantitative skills. CONCLUSION: Prevention of white matter injury would substantially improve cognitive outcomes for LBW infants.

Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force.

Associations between affective disorders, anxiety disorders, and substance use disorders were examined in epidemiological studies conducted in Germany, Switzerland, Puerto Rico, and the mainland US. There was a remarkable degree of similarity across studies in the magnitude and type of specific disorders associated with the affective disorders. Comorbidity with affective disorders was greater for the anxiety disorders than for substance misuse. Panic disorder was the subtype of anxiety that was most highly comorbid with depression. Social phobia was the specific phobic type with the strongest association with the affective disorders. The magnitude of associations between substance misuse and affective disorders generally was quite low and less consistent across sites. No major differences were found in the patterns of comorbidity by gender or age group, affective subtype or prevalence period. The onset of anxiety disorders generally preceded that of depression, whereas alcohol misuse was equally likely to pre-or post-date the onset of affective disorders. Finally, comorbidity was associated with an elevation in treatment rates across all sites, confirming Berkson's paradox on an international level.