Developmental Trajectories for Visuo-Spatial Attention are Altered by Prenatal Alcohol Exposure: A Longitudinal FMRI Study.

Functional magnetic resonance imaging (fMRI) reveals brain activation abnormalities during visuo-spatial attention and working memory among those with fetal alcohol spectrum disorders (FASD) in cross-sectional reports, but little is known about how activation changes over time during development within FASD or typically developing children. We studied 30 controls and 31 individuals with FASD over 2 years (7-14 years at first participation) with a total of 122 scans, as part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders. Despite comparable performance, there were significant group differences in visuo-spatial activation over time bilaterally in frontal, parietal, and temporal regions. Controls showed an increase in signal intensity in these multiple regions whereas FASD participants showed a decrease in brain activation. Effects were also found in 2 small independent samples from the USA, corroborating the findings from the larger group. Results suggest that the long-lasting effect of prenatal alcohol may impact the maturation of visuo-spatial attention and differentiate those with FASD from controls. Based on this first longitudinal fMRI study in FASD children, our novel findings suggest a possible neural mechanism for attention deficits common among individuals with FASD.

No clinical difference between fixed- and mobile-bearing cruciate-retaining total knee arthroplasty: a prospective randomized study.

PURPOSE: It is hypothesized that mobile polyethylene bearings in total knee arthroplasty (TKA) may confer benefits with regard to range of motion and have improved clinical outcome scores in comparison with an arthroplasty with a fixed-bearing design. Our study compares clinical outcomes between patients who undergo TKA with either a rotating platform or fixed bearing using a posterior cruciate-retaining design. METHODS: Three hundred and thirty-one patients were randomized to receive either a rotating-platform (161 patients) or a fixed-bearing (170 patients) implant. All patients were assessed pre-operatively and at 1 and 2 years post-operatively using standard tools (range of movement, Oxford Knee Score, American Knee Society Score, SF12 and Patella Score). RESULTS: There was no difference in pre- to 2-year post-operative outcomes between the groups with regard to improvement in range of motion (10° ± 16 vs. 9° ± 15), improvement in Oxford Knee Score (-17.6 ± 9.9 vs. -19.1 ± 8.4), improvement in American Knee Society Score (49.5 ± 24.7 vs. 50.7 ± 21.0), function (23.6 ± 19.6 vs. 25.0 ± 22.5) and pain (34.9 ± 16.2 vs. 35.8 ± 14.1) subscores, improvement in SF12 Score (10.0 ± 16.3 vs. 12.3 ± 15.8) or improvement in Patella Score (9.7 ± 7.4 vs. 10.6 ± 7.1). CONCLUSION: No difference was demonstrated in clinical outcome between patients with a rotating-platform and fixed-bearing posterior cruciate-retaining TKA at 2-year follow-up. LEVEL OF EVIDENCE: I.

Emotion-related learning in individuals prenatally exposed to alcohol: an investigation of the relation between set shifting, extinction of responses, and behavior.

The association between deficits in emotion-related learning, conceptual set shifting, and behavioral problems was investigated in individuals with substantial prenatal alcohol exposure. Twenty subjects with confirmed prenatal alcohol exposure (10 of whom were diagnosed as having Fetal Alcohol Syndrome) and 20 normal controls matched for age, gender, and ethnic background participated. The two groups were administered a battery of tests including two tests of emotion-related learning (visual discrimination reversal and extinction of reward-response associations), tests of conceptual set shifting and intellectual ability, and behavioral measures. The alcohol-exposed group made fewer reversals than the control group in visual discrimination reversal and exhibited more variability in extinction. These group differences remained significant after controlling for intellectual ability and conceptual set shifting. Variability in extinction and two measures of set shifting, perseverative errors on the Wisconsin Card Sorting Test and omission errors on reversal learning, were found to be robust predictors of parent-rated behavioral problems.

A comparative study of abused and neglected American Indian children in the southwest.

Samples of target and control American Indian children in the Southwest United States are compared for child abuse/neglect and family alcohol abuse. Alcohol abuse is present in virtually all families that abuse/neglect children. However, alcohol abuse exists exclusive of the association with child abuse/neglect. The study demonstrates that alcohol abuse is a necessary, but not sufficient, condition for child abuse/neglect.

Prevention of alcohol misuse: a review of health promotion efforts among American Indians.

PURPOSE: The purpose of this review is to provide an overview of a wide range of potentially useful strategies to address the prevention of alcohol misuse among American Indians. This broad approach to the review is useful because the extreme heterogeneity of the American Indian population requires that health promotion professionals explore many options and tailor their activities to specific communities. SEARCH METHOD: A literature search was initiated through MEDLINE using the following key words: prevention, alcohol, substance abuse, American Indian, and Native American. The search yielded 29 articles from the years 1982 through 1994. These articles, along with 45 previously identified in three overview articles, form the basis of the review and discussion in this paper. SUMMARY OF FINDINGS: As a group, American Indians experience many health problems that are related to alcohol misuse. Comparison of Indians to non-Indians shows that the age of first involvement with alcohol is younger, the frequency and amount of drinking is greater, and negative consequences are more common. Health promotion programs that address these issues must take into account American Indian heterogeneity and should use a comprehensive approach that addresses both heavy drinking and the sequelae of problems related to alcohol misuse. MAJOR CONCLUSIONS: Important concepts for providing health promotion services to this population are: cultural relevance must be carefully planned and monitored; individuals in the local community must be involved; the drunken Indian stereotype must be addressed; and community empowerment should be an important goal.

A comprehensive local program for the prevention of fetal alcohol syndrome.

A hospital based, comprehensive approach to the prevention of Fetal Alcohol Syndrome and Fetal Alcohol Effects that combines clinical assessment, community outreach, and epidemiologic knowledge to attack alcohol-related birth defects is described. The program includes training of clinicians and members of the community, baseline screening of suspected children, and alcohol consumption screening of pregnant women in prenatal clinics. The major, although not exclusive, focus of the program is on tertiary prevention undertaken with women defined as "high risk" for producing alcohol affected children. Of the 48 women referred to the program at the Tuba City, AZ, Indian Medical Center between January 1988 and July 1989, 39 (81 percent) became participants. Complete followup was possible on 31; 17 of them reported alcohol abstinence in July 1989, 18 months into the program. Of the 29 referred women who were pregnant at the time, 21 agreed to participate; of these, 19 (85.7 percent) were abstinent by the third trimester of pregnancy; 5 voluntarily accepted offers of contraceptive measures after the birth of their child.

Alcohol and drug misuse prevention programs for American Indians: needs and opportunities.

General statistics have indicated that the problem of alcohol and drug misuse among American Indians has been in need of attention for years. A specific and critical examination of mortality and morbidity statistics yields a number of valuable insights to the ways of addressing the problem. The current status in many communities dictates intervention at three levels. First, high mortality and morbidity rates must be reduced through creative and innovative intervention with the social and physical environment. Alcohol legalization and other issues are discussed as distinct possibilities. Second, educational programs are needed to elevate the knowledge of American Indian communities about alcohol and drug misuse. Education should be specifically oriented to improving ability to deal with early developmental problems that might lead to misuse. Third, American Indian rehabilitation programs need to be upgraded and improved by gaining more resources and by using them more effectively. Increased use of both traditional tribal strengths and modern treatment modalities is promising. Rehabilitation programs may be even more important in the future if mortality reduction programs such as those described are successful.

Some Navajo Indian opinions about alcohol abuse and prohibition: a survey and recommendations for policy.

In this study a questionnaire was administered to a sample of Navajo Indians in the southwestern region of the reservation to examine (1) their knowledge about the consequences of alcohol abuse and (2) their opinions about alcohol abuse, the etiology of abuse and alcohol legalization. Survey responses indicate that the Navajo surveyed are quite knowledgeable about the various adverse consequences of alcohol abuse. The survey found that 52% of these Navajo adults currently drink at all, and the opinion responses generally characterize alcohol consumption, even in small amounts, as a negative behavior. Sixty-three percent of all Navajos agreed with the popular, but scientifically unsubstantiated, belief that Indians have a physical weakness to alcohol that non-Indians do not have. Alcohol legalization on the reservation is opposed by 81% of the Navajos surveyed. Opinions about alcohol use and policy do not vary greatly even when knowledge of alcohol consequences and current drinking status is considered. The article concludes with a discussion of the importance of positive, solution-oriented public education and debate for entertaining new ideas about alcohol policy and for reducing the sequelae of alcohol abuse among the Navajo.

A macro-level fetal alcohol syndrome prevention program for Native Americans and Alaska Natives: description and evaluation.

Presented here are a detailed description and outcome evaluation of a comprehensive, macro-level Fetal Alcohol Syndrome prevention program for Native Americans and Alaska Natives. The program was designed to provide native communities throughout the United States with the knowledge, skills and strategies to initiate primary, secondary and tertiary prevention measures on their own. The key to the program was the training of a cadre of trainers/advocates in all local Native American and Alaska Native communities served by the Indian Health Service. These people were then supported and assisted in their efforts through a variety of means. Evaluation results of knowledge gained indicate that the local trainers had substantial success in imparting FAS information to a variety of audiences (prenatal groups, school children and community groups). Further, the evaluation samples also indicate that the knowledge was retained by the groups over time (2-4 months) and that there may have been some general diffusion of knowledge among peers in local communities. This program is presented in the hope that it will be replicated and improved upon by similar programs using this model as a base.

Profile of abused and neglected American Indian children in the Southwest.

From both knowledge gained working in Indian communities and a major data collection program, this article examines child abuse and neglect among the Indian tribes in a southwestern state. The period of study covers 1982 through 1985. The study sample consists of 53 children targeted by the local Indian Health Service Hospital Child Protection Team as being abused and/or neglected. In addition, information on the parents, grandparents and, in a number of cases, great-grandparents are examined. The study is a secondary data analysis of clinic and hospital records and interviews with local community health care providers and tribal officials. The results indicate that alcohol abuse was present in 85% of the neglect cases and in 63% of the abuse cases. In addition, child abuse and neglect occurred simultaneously in 65% of the sample. Child abuse and neglect are found to be part of a larger phenomenon of multiproblem families which raises the issue of intergenerational perpetuation of these problems. The results underscore the importance of interagency cooperation in surveillance, treatment, and prevention, as well as more careful and thorough documentation of record maintenance.

Alcohol policy considerations for Indian reservations and bordertown communities.

For some topics, particularly in public health, summaries are dangerous because they may create the idea that a single or simple solution exists. This topic is one where a summary can create a false expectation of simplicity. There is no simple or easy solution to the problem of alcohol abuse in any community, especially reservation and bordertown communities in the western United States. The solution is complex, it must be comprehensive, and it will take a great deal of effort over time to reduce alcohol and substance abuse in any individual community. Indian communities must develop a comprehensive, consistent, and clearly defined alcohol prevention/intervention policy. Such a policy must utilize a systematic, public health approach that considers the physical, mental, and social well being of each and every individual within the region. It must address all types of problematic alcohol consumption, from sporadic alcohol consumption (light and heavy) to regular alcohol abuse and chronic alcoholism, for the problems found in Indian and bordertown communities arise from a variety of different drinking patterns. Presented in this paper are a large number of policy and prevention options that have been used successfully in human societies in various parts of the world and in the United States. The intent of the paper is to present and describe the variety of options for addressing alcohol problems that have been found to be of value in the control and reduction of alcohol abuse and related problems. The three broad categories of approach are: controlling the supply of alcoholic beverages through statute and regulation; shaping drinking practices directly; and reducing the physical and social environmental risks. Indian tribal councils and Native communities can, if they so desire, consider, debate, and enact any or all of these measures. The important issue is that they should be aware of these ideas for prevention and consider them carefully. If the preventive measures described here can be applied systematically and reasonably within the social and cultural contexts of a Native community, then the ultimate result should be positive. Readers are encouraged to read this paper carefully, to study the tables and figures, and if more detail is desired, to consult some of the many references found in the back. Comprehensive and positive alcohol policy has been ignored for too long in Indian country, and the resultant toll in morbidity, mortality, and suffering is too high. This paper presents the ingredients for a comprehensive policy. Each community need to work its own recipe.

A multiple-level, comprehensive approach to the prevention of fetal alcohol syndrome (FAS) and other alcohol-related birth defects (ARBD).

A comprehensive program for the prevention of fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD) must consider multiple approaches and utilize knowledge from a variety of academic disciplines. Issues related to culture, society, behavior, belief systems, and medicine must all be considered for both etiology and solutions. A broad paradigm such as a public health model integrates various elements of approach. Because FAS and other levels of ARBD form a spectrum, from severe to negligible damage, a variety of drinking patterns with various characteristics and etiologies have to be addressed. This paper describes a multiple-level, comprehensive program with primary, secondary, and tertiary prevention components. Practical recommendations are proposed for addressing ARBD in a variety of arenas. While secondary and tertiary prevention hold promise for short-term reduction of FAS and ARBD prevalence, comprehensive prevention serves both short- and long-term effects. Multiple level prevention efforts are well served by clear and compelling vision and mission statements, and require careful evaluation.

Substance abuse and American Indians: prevalence and susceptibility.

The use of alcohol and other substances by American Indians has received considerable popular attention over the years. Empirical studies of prevalence for all types of substance abuse, however, have generally been few and limited in scope. In this paper prevalence studies among Indians are reviewed and analyzed by comparison with each other and national studies. In addition, issues important to the research of Indian alcohol and drug abuse are discussed. Finally a specific scheme of susceptibility is proposed which may explain the patterns of variation in both tribal and individual substance abuse.