Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.

Integrating social and emotional learning (SEL) programming throughout curricula to support the development of healthy behaviors and prevent violence is critical for a comprehensive approach to school health. This study used a post-test comparison design to evaluate a healthy relationships program for eighth grade students that applies a SEL approach. The program was adapted from the Fourth R, an evidence-based program for ninth graders, but matches the curriculum and developmental context for eighth graders. Surveys were collected post-intervention from 1012 students within 57 schools randomized to intervention or control conditions. Multivariate multilevel analysis accounted for the nested nature of students within schools. There were significant group differences on three of four outcomes following intervention, including improved knowledge about violence, critical thinking around the impact of violence, and identification of more successful coping strategies. There was no group difference on general acceptance of violence. Overall, students learned relevant information and strategies and were able to apply that knowledge to demonstrate critical thinking, suggesting that adapting an evidence-based approach for use with younger students provided similar benefits. These findings build a case for 2 years of consecutive evidence-based healthy relationships programming in grades 8 and 9, consistent with best practice guidelines.

White blood cell count and incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in African-American and White men and women: atherosclerosis risk in communities study.

The authors examined the association between white blood cell (WBC) count and incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in 13,555 African-American and White men and women from the Atherosclerosis Risk in Communities (ARIC) Study. Blood was drawn at the ARIC baseline examination, beginning in 1987-1989. During an average of 8 years of follow-up (through December 1996), there were 488 incident coronary heart disease events, 220 incident strokes, and 258 deaths from cardiovascular disease. After adjustment for age, sex, ARIC field center, and multiple risk factors, there was a direct association between WBC count and incidence of coronary heart disease (p < 0.001 for trend) and stroke (p for trend < 0.001) and mortality from cardiovascular disease (p for trend < 0.001) in African Americans. The African Americans in the highest quartile of WBC count (> or =7,000 cells/mm(3)) had 1.9 times the risk of incident coronary heart disease (95% confidence interval (CI): 1.19, 3.09), 1.9 times the risk of incident ischemic stroke (95% CI: 1.03, 3.34), and 2.3 times the risk of cardiovascular disease mortality (95% CI: 1.38, 3.72) as their counterparts in the lowest quartile of WBC count (<4,800 cells/mm(3)). These associations were similar in Whites and in never smokers. An elevated WBC count is directly associated with increased incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in African-American and White men and women.

Development and validation of the Conflict in Adolescent Dating Relationships Inventory.

Four studies examined the Conflict in Adolescent Dating Relationships Inventory (CADRI), a measure of abusive behavior among adolescent dating partners. Exploratory factor analysis was used to refine items based on high school participants with dating experience (N = 393; 49% female). Confirmatory factor analysis was used to derive and cross-validate the factor structure with participants from 10 high schools (N = 1,019, 55% female; ages 14-16). The model structure fit for all grades and both sexes, with physical abuse, verbal abuse, and threatening behavior most representative of the underlying "abuse" factor. In Studies 3 and 4, the second-order abuse factor showed acceptable test-retest reliability, partner agreement, and correlation (significant for males only) between observer ratings of dating partners' interactions and youths' CADRI scores. Results support the CADRI as a measure of abusive behavior in adolescent dating relationships.

Child maltreatment: risk of adjustment problems and dating violence in adolescence.

OBJECTIVE: To examine the relationship between child maltreatment, clinically relevant adjustment problems, and dating violence in a community sample of adolescents. METHOD: Adolescents from 10 high schools (N= 1,419; response rate = 62%) in southwestern Ontario completed questionnaires that assessed past maltreatment, current adjustment, and dating violence. Logistic regression was used to compare maltreated and nonmaltreated youths across outcome domains. RESULTS: One third (n = 462) of the school sample reported levels of maltreatment above the cutoff score on the Childhood Trauma Questionnaire. Girls with a history of maltreatment had a higher risk of emotional distress compared with girls without such histories (e.g., odds ratios [OR] for anger, depression, anxiety, and posttraumatic stress-related problems were 7.1, 7.2, 9.3, and 9.8, respectively). They were also at greater risk of violent and nonviolent delinquency (OR = 2.7) and carrying concealed weapons (OR = 7.1). Boys with histories of maltreatment were 2.5 to 3.5 times as likely to report clinical levels of depression, posttraumatic stress, and overt dissociation as were boys without a maltreatment history. They also had a significantly greater risk of using threatening behaviors (OR = 2.8) or physical abuse (OR = 3.4) against their dating partners. CONCLUSIONS: Maltreatment is a significant risk factor for adolescent maladjustment and shows a differential pattern for male and female adolescents.

Ibutilide: a class III rapidly acting antidysrhythmic for atrial fibrillation or atrial flutter.

Ibutilide is an intravenous Class III antidysrhythmic approved for the treatment of recent onset atrial fibrillation or atrial flutter. Pharmacological effect occurs within 30 min, and the efficacy approaches 40%. In contrast to DC electrical cardioversion, which requires anesthesia, pharmacologic cardioversion offers an alternative in which sedation can be avoided. Patients receiving ibutilide should be monitored for at least 4 h after completed drug administration because of a small chance of ventricular dysrhythmia, mainly torsades de pointes. Careful patient selection is the key to avoiding dysrhythmic complications. The purpose of this article is to review the mechanisms, clinical applications, potential complications, and appropriate use of ibutilide.

Childhood maltreatment, posttraumatic stress symptomatology, and adolescent dating violence: considering the value of adolescent perceptions of abuse and a trauma mediational model.

The present study, utilizing both a child protective services and high school sample of midadolescents, examined the issue of self-report of maltreatment as it relates to issues of external validity (i.e., concordance with social worker ratings). reliability (i.e.. overlap with an alternate child maltreatment self-report inventory; association of a self-labeling item as "abused" with their subscale item counterparts), and construct validity (i.e., the association of maltreatment with posttraumatic stress symptomatology and dating violence). Relevant theoretical work in attachment, trauma, and relationship violence points to a mediational model, whereby the relationship between childhood maltreatment and adolescent dating violence would be expected to be accounted for by posttraumatic stress symptomatology. In the high school sample, 1329 adolescents and, in the CPS sample, 224 youth on the active caseloads completed comparable questionnaires in the three domains of interest. For females only, results supported a mediational model in the prediction of dating violence in both samples. For males, child maltreatment and trauma symptomatology added unique contributions to predicting dating violence. with no consistent pattern emerging across samples. When considering the issue of self-labeling as abused. CPS females who self-labeled had higher posttraumatic stress symptomatology and dating violence victimization scores than did their nonlabeling, maltreated counterparts for emotional maltreatment. These results point to the need for ongoing work in understanding the process of disclosure and how maltreatment experiences are consciously conceptualized.

Dating violence in mid-adolescence: theory, significance, and emerging prevention initiatives.

Adolescent dating violence is an important juncture in the developmental pathway to adult partnership violence. As a window of opportunity for positive change, the present review considers the theoretical and empirical work on adolescent dating and dating violence. A consideration of the scope of the problem, developmental processes, and theoretical formulations precede a review of six relationship violence prevention programs designed for and delivered to youth. Five programs are school-based and one operates in the community. Prevention is targeted toward both universal (e.g., all high school students) and selected adolescent populations (e.g., youths with histories of maltreatment, or problems with peer aggression). Programs addressed specific skills and knowledge that oppose the use of violent and abusive behavior toward intimate partners; one program addressed interpersonal violence more generally, and was also included in this review because of its implications for dating violence initiatives. Positive changes were found across studies in violence-related attitudes and knowledge, also, positive gains were noted in self-reported perpetration of dating violence, with less consistent evidence in self-reported victimization. However, these findings should be considered preliminary due to limited follow-up and generalizability. Conceptual and methodological issues are discussed with a view toward improving assessment methods and research design.

Emerging strategies in the prevention of domestic violence.

Responses to domestic violence have focused, to date, primarily on intervention after the problem has already been identified and harm has occurred. There are, however, new domestic violence prevention strategies emerging, and prevention approaches from the public health field can serve as models for further development of these strategies. This article describes two such models. The first involves public health campaigns that identify and address the underlying causes of a problem. Although identifying the underlying causes of domestic violence is difficult--experts do not agree on causation, and several different theories exist--these theories share some common beliefs that can serve as a foundation for prevention strategies. The second public health model can be used to identify opportunities for domestic violence prevention along a continuum of possible harm: (1) primary prevention to reduce the incidence of the problem before it occurs; (2) secondary prevention to decrease the prevalence after early signs of the problem; and (3) tertiary prevention to intervene once the problem is already clearly evident and causing harm. Examples of primary prevention include school-based programs that teach students about domestic violence and alternative conflict-resolution skills, and public education campaigns to increase awareness of the harms of domestic violence and of services available to victims. Secondary prevention programs could include home visiting for high-risk families and community-based programs on dating violence for adolescents referred through child protective services (CPS). Tertiary prevention includes the many targeted intervention programs already in place (and described in other articles in this journal issue). Early evaluations of existing prevention programs show promise, but results are still preliminary and programs remain small, locally based, and scattered throughout the United States and Canada. What is needed is a broadly based, comprehensive prevention strategy that is supported by sound research and evaluation, receives adequate public backing, and is based on a policy of zero tolerance for domestic violence.

The role of child maltreatment and attachment style in adolescent relationship violence.

Utilizing attachment theory as a basis for conceptualizing close relationships among adolescents, this study investigated two important relationship risk factors (child maltreatment, and adolescent self-perceived insecure attachment style) as predictors of "offender" and "victim" experiences in youth relationships. In addition to considering the influence of these risk factors, we further considered their interaction in predicting conflict in close relationships. Of interest was the extent to which attachment styles may function as a moderator of the relationship between childhood abuse and current abuse in teen close relationships. High school students (N = 321) in grades 9 and 10 completed questionnaires tapping their histories of maltreatment, currently viewed styles of attachment, and conflict in close relationships over the past 6 months. Maltreatment alone emerged as the most consistent predictor, accounting for 13-18% of the variance in male's physically, sexually, and verbally abusive behaviors; in contrast, it was not highly predictive of female's abusive behaviors. Maltreatment was predictive of victimization experiences for both males and females. Attachment style did not substantially add to the prediction of relationship conflict beyond maltreatment; however, avoidant attachment style emerged repeatedly as a significant predictor of female abusiveness and victimization. Attachment self-ratings were found to function as a moderator of child maltreatment in predicting primarily male coercive behavior towards a relationship partner as well as predicting male's experience of coercion from a partner. Thus, the presence of childhood maltreatment and adolescent self-perceived insecure attachment style applies predominantly to male youth. The implication of these gender differences for understanding relationship violence is discussed.

Factors associated with abusive relationships among maltreated and nonmaltreated youth.

This study sought to understand how experiences of maltreatment occurring prior to 12 years of age affect adolescent peer and dating relationships. A school-based sample of 15-year-olds was divided into maltreated (n = 132) and nonmaltreated (n = 227) subgroups based on self-reported maltreatment. These two groups were then compared on two theoretically determined dimensions of adjustment (i.e., interpersonal sensitivity/hostility; personal resourceS) and self- and teacher-report measures of peer and dating relationships. Findings supported the hypothesis that maltreated youths significantly differed from nonmaltreated youths in terms of adjustment problems as well as conflict with dating partners and close friends. Maltreated youths reported significantly more verbal and physical abuse both toward and by their dating partners, and were seen by teachers as engaging in more acts of aggression and harassment toward others. In regression analyses, the significant association between maltreatment and dating conflict for males was strengthened by including adjustment dimensions in the equation; for females, adjustment variables mediated the association between maltreatment and dating conflict. Results are discussed in relation to a maladaptive interpersonal trajectory for maltreated children, wherein a violent interactional dynamic in adolescent close relationships may be setting the stage for violence in intimate partnerships.

Catheter ablation for atrial flutter and fibrillation. An effective alternative to medical therapy.

Atrial flutter and atrial fibrillation are common arrhythmias that can be difficult to manage clinically. In many patients, these conditions are refractory to pharmacologic therapy because of drug failure or intolerance. Radiofrequency catheter ablation may be a reasonable alternative in patients with typical atrial flutter. The procedure has a high initial success rate and a low complication rate. However, recurrence after ablation is common, and a second treatment session may be needed. In selected patients with atrial fibrillation, radiofrequency ablation can be useful for rate control. However, its use in curing chronic fibrillation is still experimental. The procedure involves insertion of a pacemaker, anticoagulation therapy is still needed in most patients, and the need for antiarrhythmic medication may not be obviated.

Update on implantable cardioverter-defibrillators. New, safer devices have led to changes in indications.

The safety and efficacy of ICDs have improved significantly in the past few years. Recent evidence supports the value of these devices not only for secondary prevention of sudden cardiac death, but also for primary prevention in post-myocardial infarction patients with poor left ventricular function, unsustained ventricular tachycardia, and inducible ventricular tachycardia on electrophysiologic study. Transvenous defibrillation using the defibrillator case as the high-voltage electrode and a biphasic shock is currently the procedure of choice. Implantation is simple, and the defibrillation thresholds are acceptably low. However, the possibility of interactions must be considered in patients with cardiac pacemakers.

Test for qualitative interaction of clinical significance.

We generalize the problem of detecting qualitative interaction between treatments and subsets in a two treatment clinical trial to the more practical problem of detecting a qualitative interaction greater than a non-negative value d, corresponding to the minimal treatment difference of clinical significance. We develop a test based on simultaneous confidence intervals for the generalized problem under the assumption of normality. The proposed test is easy to implement, either by hand calculation or through the use of virtually any existing statistical software. We derive explicit power function for the proposed test and give examples to illustrate the procedures.

Nonparametric tests for comparing umbrella pattern treatment effects with a control in a randomized block design.

This paper treats the problem of comparing umbrella pattern treatment effects with a control in a randomized block design. An extension of the Chen-Wolfe test (1993, Biometrics 49, 455-465) and its modification are proposed for both cases where the peak of the umbrella is known or unknown. Approximate critical values are given and the results of a Monte Carlo power study are presented.

PMMA bead versus parenteral treatment of Staphylococcus aureus osteomyelitis.

A. rabbit model of Staphylococcus aureus osteomyelitis was used to compare 3 weeks of clindamycin-impregnated polymethylmethacralate (PMMA) bead treatment with 3 weeks of gentamicin-impregnated polymethylmethacralate bead treatment, 4 weeks of parenteral clindamycin treatment, and surgical debridement without any antibiotic treatment. The animals were weighed throughout the course of the experiment and cortical bone and marrow flush specimens were obtained for bacterial culture at the end of therapy. The cortical specimens were bacteria free in 100% (6/6) of the animals receiving parenteral clindamycin, 83% (5/6) of the animals in the clindamycin PMMA group and, none of the animals in the gentamicin PMMA group. The marrow flush specimens were bacteria free in 83% (5/6) of the animals in the parenteral clindamycin group, 67% (4/6) of the animals in the clindamycin PMMA group, and 40% (2/5) of the animals in the gentamicin PMMA group. While these findings are preliminary and further studies with larger numbers of animals are needed, the authors suggest that when PMMA bead therapy is being contemplated, serious consideration should be given to replacing gentamicin with clindamycin in treatment of gram-positive osteomyelitis. Furthermore, incorporation of clindamycin with gentamicin (or tobramycin) should be considered when treating mixed gram-positive and gram-negative osteomyelitis.

Multiple maltreatment experiences and adolescent behavior problems: adolescents' perspectives.

By adolescence, appraisal of one's past life experience becomes critical to the stage-salient issue of identity formation. This study examined adolescents' perceptions of their maltreatment experiences. It scrutinized the combined and unique contribution of five maltreatment types (i.e., physical abuse, sexual abuse, psychological abuse, neglect, and exposure to family violence) to variance in adolescent adjustment. It was predicted that these maltreatment types would account for significant variance in adjustment when controlling for the context variables of age, sex, socioeconomic status, IQ, and stressful life events. Adolescents (N = 160, aged 11-17) were randomly selected from the open caseload of a child protection agency. Participants completed global severity ratings regarding their experiences of the five types of maltreatment, as well as a battery of measures assessing self- and caretaker-reported externalizing and internalizing symptomatology. The youths' maltreatment ratings significantly predicted self-reported adjustment, even when controlling for all context variables. Psychological maltreatment was the most predictively potent maltreatment type, and enhanced the predictive utility of other maltreatment types. Significant sex differences in the sequelae of perceived maltreatment were evident. Also, interactions between youths' ratings and those obtained from CPS files were detected. The findings were consistent with recent research in child maltreatment, and contribute to our understanding of developmental psychopathology among adolescents.

The measurement of maltreatment: a comparison of approaches.

This study examined the comparability and predictive validity of three approaches to the measurement of child maltreatment. Adolescents (N = 160, aged 11-17) were randomly selected from the open caseload of a child protection agency. Global ratings of maltreatment severity were made by three reporting sources: researchers on the basis of protection agency case files, protection agency social workers, and the adolescents themselves. Ratings were made of five types of maltreatment: physical, sexual, emotional, neglect, and exposure to family violence. Self-reported (YSR) and caretaker-reported (CBCL) adjustment measures were also obtained for each subject. Results indicated that over 90% of the sample had experienced more than one type of maltreatment. Comparison of ratings across sources indicated considerable disagreement with respect to judgments of maltreatment occurrence and severity. Relative to professional ratings, adolescent ratings were better predictors of externalizing and internalizing symptomatology in both univariate and multivariate analyses.

Witnessing domestic violence during childhood and adolescence: implication for pediatric practice.

The traditional role of the pediatrician, which consisted primarily of making diagnoses and prescribing treatments for specific disease entities in children, has expanded dramatically to include psychosocial aspects of health care as well as problems that are primarily psychological, emotional, or social in nature and that extend in various ways to the family and to the child's environment. One of these problems has been identified as the manner in which witnessing domestic violence, a significant and relatively commonplace event for many children today, affects child development and behavior. This paper reviews our existing knowledge of such events and explores how exposure to conflict and violence plays a major role in how children learn to relate to others, how they develop their self-concept and self-control, and how they interact with dating and marital partners in the future. We conclude with a discussion of the role of the pediatrician in interviewing children and other family members and in identifying appropriate avenues for prevention and treatment. Major recommendations derived from this paper include: decreasing the attitudinal barriers to exploring this issue; increasing sensitivity to clinical features and behavioral symptoms of children who witness domestic violence; and increasing knowledge of available resources for treatment and prevention.