Opioid use disorder during pregnancy: An overview.

Women with opioid use disorder who become pregnant are a particularly vulnerable population and require a comprehensive treatment approach for mother and fetus. Research is continuing on opioid use disorder, effects of opioid use on the fetus, and best treatment approaches. This article reviews current recommendations and guidelines for treatment.

Isolated left homonymous hemianopia secondary to a pericatheter cyst-a rare presentation of a ventriculoperitoneal shunt failure.

A 26-year-old woman developed a left homonymous hemianopia 1 week after placement of a ventriculoperitoneal shunt through a right parieto-occipital approach. Computed tomography demonstrated a parenchymal cyst in the right occipital lobe. After shunt revision, there was concomitant resolution of the cyst and visual field defect over 1 month. The literature is reviewed regarding this unusual complication of ventriculoperitoneal shunt failure.

A double-blind placebo-controlled trial of N-acetylcysteine in the treatment of cocaine dependence.

BACKGROUND: There remains no FDA approved medication for the treatment of cocaine dependence. Preclinical studies and early pilot clinical investigations have suggested that N-acetylcysteine (NAC) may be useful in the treatment of the disorder. OBJECTIVE: The present report assessed the efficacy of NAC in the treatment of cocaine dependence. METHODS: Cocaine-dependent volunteers (n = 111) were randomized to receive daily doses of 1,200 mg of NAC, 2,400 mg of NAC, or placebo. Participants were followed for 8 weeks (up to three visits weekly). At each of these visits, urine samples were collected, along with self-reports of cocaine use. Urine samples were assessed for quantitative levels of benzoylecognine (ie, cocaine metabolite). RESULTS: Overall, the primary results for the clinical trial were negative. However, when considering only subjects who entered the trial having already achieved abstinence, results favored the 2,400 mg NAC group relative to placebo, with the 2,400 mg group having longer times to relapse and lower craving ratings. CONCLUSION: While the present trial failed to demonstrate that NAC reduces cocaine use in cocaine-dependent individuals actively using, there was some evidence it prevented return to cocaine use in individuals who had already achieved abstinence from cocaine. SCIENTIFIC SIGNIFICANCE: N-acetylcysteine may be useful as a relapse prevention agent in abstinent cocaine-dependent individuals.

Comparison of Methods for Identifying Phenotype Subgroups Using Categorical Features Data With Application to Autism Spectrum Disorder.

We evaluate the performance of the Dirichlet process mixture (DPM) and the latent class model (LCM) in identifying autism phenotype subgroups based on categorical autism spectrum disorder (ASD) diagnostic features from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision. A simulation study is designed to mimic the diagnostic features in the ASD dataset in order to evaluate the LCM and DPM methods in this context. Likelihood based information criteria and DPM partitioning are used to identify the best fitting models. The Rand statistic is used to compare the performance of the methods in recovering simulated phenotype subgroups. Our results indicate excellent recovery of the simulated subgroup structure for both methods. The LCM performs slightly better than DPM when the correct number of latent subgroups is selected a priori. The DPM method utilizes a maximum a posteriori (MAP) criterion to estimate the number of classes, and yielded results in fair agreement with the LCM method. Comparison of model fit indices in identifying the best fitting LCM showed that adjusted Bayesian information criteria (ABIC) picks the correct number of classes over 90% of the time. Thus, when diagnostic features are categorical and there is some prior information regarding the number of latent classes, LCM in conjunction with ABIC is preferred.

Application of beta regression to analyze ischemic stroke volume in NINDS rt-PA clinical trials.

BACKGROUND AND PURPOSE: Ischemic stroke lesion volumes have proven difficult to analyze due to the extremely skewed shape of their underlying distribution. We introduce an extension of generalized linear models, beta regression, as a possible method of modeling extremely skewed distributions as evidenced in ischemic stroke lesion volumes. METHODS: The NINDS rt-PA clinical trials measured ischemic stroke lesion volume as a secondary trial outcome. Three-month lesion volumes from these trials were analyzed using beta regression. A multi-variable regression model associating explanatory variables with ischemic stroke lesion volumes was constructed using accepted model building strategies and compared with the previously published volumetric analysis. RESULTS: Beta regression produced a similar model when compared to the previous analysis published by the study group. All previously identified variables of importance were detected in the model building process. The age by treatment interaction described in previous studies was also found in this analysis, confirming the strong effect age has on stroke outcomes. Further, a treatment effect was elicited in terms of odds ratios, yielding a previously unknown quantification of the effect of rt-PA on lesion volumes. CONCLUSIONS: Beta regression proved adept in modeling ischemic stroke lesions and offered the interpretation of covariates in terms of odds ratios. Beta regression is seen as a legitimate alternative to analyze ischemic stroke volumes.

The association of drinking water quality and sewage disposal with Helicobacter pylori incidence in infants: the potential role of water-borne transmission.

The mode of transmission of Helicobacter pylori, a bacterium causing gastric cancer and peptic ulcer disease, is unknown although waterborne transmission is a likely pathway. This study investigated the hypothesis that access to treated water and a sanitary sewerage system reduces the H. pylori incidence rate, using data from 472 participants in a cohort study that followed children in Juarez, Mexico, and El Paso, Texas, from April 1998, with caretaker interviews and the urea breath test for detecting H. pylori infection at target intervals of six months from birth through 24 months of age. The unadjusted hazard ratio comparing bottled/vending machine water to a municipal water supply was 0.71 (95% confidence interval (CI): 0.50, 1.01) and comparing a municipal sewer connection to a septic tank or cesspool, 0.85 (95% CI: 0.60, 1.20). After adjustment for maternal education and country, the hazard ratios decreased slightly to 0.70 (95% confidence interval: 0.49, 1.00) and 0.77 (95% confidence interval: 0.50, 1.21), respectively. These results provide moderate support for potential waterborne transmission of H. pylori.

Racial/ethnic disparities in the identification of children with autism spectrum disorders.

OBJECTIVES: We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs). METHODS: Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education. RESULTS: Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70. CONCLUSIONS: Significant racial/ethnic disparities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD.

The effect of maternal smoking during pregnancy on intellectual disabilities among 8-year-old children.

Prenatal tobacco smoke exposure has been implicated as a risk factor for cognitive deficits in children. The purpose of this study is to examine the association between prenatal tobacco smoke exposure and diagnosis of intellectual disabilities (ID) among 8-year-old children living in Arkansas, Georgia, North Carolina and Utah. In 2002 and 2004, 965 ID case children were identified through a surveillance network and compared with the population of children born in the surveillance region during the same period (n = 104 607). Prenatal tobacco smoke exposure was determined from birth certificates. We estimated the effect of prenatal tobacco smoke exposure (none, <10, 10-19 and > or =20 cigarettes per day) on ID using logistic regression. Generally, the risk of ID was mildly elevated among children whose mothers smoked > or =20 cigarettes per day during pregnancy [RR 1.34; 95% (confidence interval) CI 0.96, 1.87] after adjustment for maternal education, maternal race, maternal age, marital status, child sex, birth year and study site. However, the effect of exposure to > or =20 cigarettes per day significantly differed for males [RR 1.77, 95% CI 1.20, 2.62] compared with females [RR 0.81, 95% CI 0.44, 1.50]. Supplemental analyses reveal substantial confounding of this relationship by socio-economic indicators. A differential effect of tobacco smoke exposure on the risk of ID is suggested for males and females and deserves further investigation; however, the interpretation is tempered by the potential for residual confounding.

Pre-existing health conditions and repeat traumatic brain injury.

OBJECTIVE: To assess and compare the effect of Pre-existing epilepsy/seizure disorder and drug/alcohol problem on the hazard of repeat traumatic brain injury (TBI) in persons with TBI who participated in a follow-up study. DESIGN: Retrospective cohort. SETTING: Acute care hospitals in South Carolina. PARTICIPANTS: Participants were from the South Carolina Traumatic Brain Injury Follow-up Registry cohort of persons (N=2118) who were discharged from an acute care hospital in South Carolina and who participated in a year-1 follow-up interview. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Repeat TBI was defined by 2 isolated events of TBI in the same person at least 72 hours apart and recorded in hospital discharge or emergency department records from 1999 through 2005. RESULTS: A Cox proportional hazards model was used to assess the associations of Pre-existing epilepsy/seizure disorder and drug/alcohol problem with time to repeat TBI, controlling for other confounding factors. There were 2099 persons with information on both Pre-existing conditions. There were 147 (7%) persons who sustained repeat TBI after recruitment to the follow-up study, and 82 (3.9%) had a previous TBI before recruitment for which they were seen in the hospital discharge or emergency department since 1996. The hazard of repeat TBI for persons with Pre-existing epilepsy/seizure disorder was 2.3 times the hazard for those without (hazard ratio, 2.3; 95% confidence interval, 1.2-4.4; P=.011). Pre-existing drug/alcohol problem was not associated with repeat TBI. Other variables significantly associated with repeat TBI were having a prior TBI, being insured under Medicaid, and having no insurance. CONCLUSIONS: Pre-existing epilepsy/seizure disorder predisposes to repeat TBI. Appropriate management of seizure control may be an important strategy to allay the occurrence of repeat TBI.

Use and determinants of the methylprednisolone protocol for traumatic spinal cord injury in South Carolina acute care hospitals.

BACKGROUND: The use of methylprednisolone sodium succinate (MPSS) in the treatment of traumatic spinal cord injury was initially reported to enhance recovery in the National Acute Spinal Cord Injury Studies (NASCIS), 1990 and 1997. Controversy led to subsequent research and a 2002 report citing insufficient evidence for MPSS treatment standards or guidelines. Our purpose was to explore emergency department (ED) response to this shifting information by assessing the impact of NASCIS and the 2002 report on MPSS protocols and to study factors associated with MPSS administration. METHODS: Availability of protocols and hospital characteristics were determined by survey of all hospitals with EDs in South Carolina. Protocol copies were obtained and reviewed for accuracy based on NASCIS. Patient hospital discharge information was collected through the state Office of Research and Statistics, and factors associated with receiving MPSS were evaluated using multivariable techniques. RESULTS: Having a protocol was associated with trauma level designation and volume of traumatic spinal cord injury patients per annum, with 100% of Level I trauma facilities having a protocol. Across all trauma levels, 40% of reporting EDs had an MPSS protocol, with 86% of these accurate, and none withdrawn during the study. Patient factors associated with being less likely to receive MPSS were female gender, injury below thoracic level, and treatment in an undesignated trauma center. CONCLUSIONS: Shifting information on the benefit of MPSS did not lead to withdrawal of protocols over the study time period. However, within those hospitals having a protocol, only 32% of eligible patients received MPSS treatment.

Traumatic spinal cord injury mortality, 1981-1998.

BACKGROUND: We aim to assess the long-term trend of and identify risk factors for traumatic spinal cord injury (TSCI) mortality from 1981 through 1998 in the state of South Carolina (SC). METHODS: We analyzed data from the TSCI surveillance system in SC. Poisson regression analyses were used to examine trends in TSCI mortality rates across subpopulations of interest. Multiple logistic regression was used to identify risk factors for TSCI mortality. RESULTS: The rate of TSCI mortality was 27.4 per million population between 1981 and 1998. A significant 3% annual decrease in the TSCI mortality rate was found from 1981 through 1998. Specifically, TSCI mortality rates declined the most per year in motor vehicle crashes, males, and whites. Adjusted for covariates, individuals of older ages, black race, with a cervical TSCI, and with a more severe injury, as defined by both Frankel grade and Abbreviated Injury Scale, were associated with higher odds of in-hospital mortality. Females had lower odds of in-hospital mortality than males. CONCLUSION: Although mortality rate is decreasing, TSCI remains a significant public health problem, with SC having higher rates of TSCI mortality than the United States. The association between gender and in-hospital mortality needs further exploration.

A population-based study of repetitive traumatic brain injury among persons with traumatic brain injury.

PRIMARY OBJECTIVE: The objective was to estimate and compare the hazards of repetitive traumatic brain injury (RTBI) events as a function of the index TBI severity, in a cohort of TBI hospital discharges include in the South Carolina Traumatic Brain Injury Follow-up Registry. RESEARCH DESIGN: Retrospective cohort. METHODS AND PROCEDURES: There were 4357 persons with TBI who were followed from the index hospital discharge through 31 December 2005 for RTBI events through the statewide hospital discharge (HD) and emergency department (ED) records. Prentice, Williams, Peterson total time/conditional probability model (PWP-CP) for recurrent events survival analysis was used to assess RTBI as a function of index TBI severity. MAIN OUTCOMES AND RESULTS: Index TBI severity approached significance in its relationship with RTBI, with persons with a severe index TBI experiencing events at a higher rate than those with a mild/moderate index TBI. Among the other covariates evaluated, epilepsy/seizure disorder, race, gender, payer status, cause of injury and having a prior history of TBI were associated with RTBI. CONCLUSIONS: While TBI severity approached significance with RTBI, other variables, such as epilepsy/seizure disorder, seem to have a more significant relationship with RTBI.

Predictors of skin cancer in commercial airline pilots.

BACKGROUND: Skin cancers among commercial airline pilots have been reported to occur at increased rates in pilot populations worldwide. The reasons for these increases are unclear, but postulated factors include ionizing radiation, circadian disruption and leisure sun exposure. AIMS: To investigate the potential association of these occupational and lifestyle factors, as well as medical history and skin type, with non-melanoma skin cancer in pilots. METHODS: Data were collected using a confidential Internet survey administered in collaboration with the Air Line Pilots Association International to all active pilots in four US commercial airlines. Pilots with non-melanoma skin cancer were compared to those without using multivariable analysis. RESULTS: The response rate was 19%. Among pilots flying <20 years prior to diagnosis, factors associated with increased odds of non-melanoma skin cancer were at-risk skin type, childhood sunburns and family history of non-melanoma skin cancer. Off-duty sunscreen use and family history of melanoma were protective. Among pilots with >or=20 years flight time prior to diagnosis, childhood sunburns and family history of non-melanoma skin cancer persisted as risk factors, with the addition of flight time at high latitude. CONCLUSIONS: Further investigation regarding the potential health impact of long-term flying at high latitudes is recommended. Additionally, occupational health programmes for pilots should stress awareness of and protection against established risk factors for non-melanoma skin cancer.

Prevalence and characteristics of children with autism-spectrum disorders.

PURPOSE: The purpose of this study was to determine the prevalence of autism spectrum disorders (ASD) and associated characteristics among 8-year-old children. METHODS: This is an ongoing active, population-based surveillance program conducted in South Carolina as part of the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network. Cases from the state's first two study years (2000 and 2002) have been combined for analysis, resulting in surveillance of 47,726 children who are 8 years of age. RESULTS: A total of 295 children met criteria for ASD, yielding a prevalence of 6.2 per 1000. The racial distribution of cases was similar to that of 8-year-old children in the study area, with boys more commonly affected than girls (3.1:1). Seventy-nine percent of cases were served in special education, 36% of these under Autism classification. Analyses by gender showed differences in diagnostic criteria and intellectual functioning. Girls more often were cognitively impaired (IQ

Performance characteristics of the posttraumatic stress disorder checklist and SPAN in Veterans Affairs primary care settings.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a treatable disorder, and individuals with this condition may benefit from early detection. Many people with PTSD are not aware of its symptoms and do not seek treatment, making a brief and targeted screening program a worthwhile endeavor. For this reason, research aimed at improving screening instruments could yield substantial benefits. OBJECTIVES: The primary objective of this research was to assess the diagnostic performance of two popular PTSD screening assessments, the PTSD Checklist (PCL) and the SPAN, in a Veterans Affairs (VA) primary care setting. Additionally, we compared the screening performance of these two assessments by sex and race. METHODS: The PCL and SPAN were compared with a gold standard, the Clinician-Administered PTSD Scale. Receiver operating characteristic curves were used in conjunction with sensitivity and specificity measures to assess the performance of each screening assessment. These analyses are based on a large database (n=1076) that was derived from a multisite cross-sectional study conducted at four southeastern VA medical centers. RESULTS: Results for the PCL support cutoff scores lower than those previously published, whereas results for the SPAN support the previously recommended cutoff score of 5 (sensitivity of 73.68% and specificity of 81.99%). We found no significant difference in areas under the curve (AUCs) by sex and by race between the PCL and SPAN. We did find that there was a highly significant difference (P<.0006) in overall diagnostic ability (as measured by the AUC) between the PCL (AUC=0.882) and SPAN (AUC=0.837), making the PCL the preferred screening tool, unless brevity is essential. CONCLUSIONS: Clinicians and researchers should consider lower cutoff scores for the PCL, but the originally suggested cutoff score for the SPAN is appropriate.

Geographical patterns of end-stage renal disease incidence and risk factors in rural and urban areas of South Carolina.

To assess the geographical patterns of end-stage renal disease (ESRD) incidence and to identify the risk factors on the regional differences, the authors conducted an ecological study on incidence of ESRD and related risk factors in the 46 counties of South Carolina (SC). Age and gender adjusted, race specific incidence rates for each county in SC were calculated for the 11,346 ESRD patients of all ages who registered in the United States Renal Data Systems Network 6 from 1990 to 1999. County level exposure measures on population physician density, hospitalization rates of diabetes and hypertension, per capita income, percent college degree, and percent below poverty were evaluated. There was a significant increase in mean incidence rates of ESRD from 1990 to 1999 in SC (p<0.0001). The incidence rates were consistently higher in rural than in urban counties. Population physician density (relative risk (RR) 0.49, 95% confidence interval (95%Cl, 0.41-0.58) and rural residence (adjusted RR 1.66, 95%Cl 1.59-1.74) were significantly associated with ESRD incidence. The strong relationship between ESRD and physician density suggests that access to adequate treatment of diabetes and hypertension is of paramount importance for ESRD prevention, and has important public policy implications.

A New Source of Nonprofit Neurosurgical Funding.

The purpose of this paper is to propose and qualify a novel funding mechanism for international neurosurgical nonprofits. The article first identifies and explains neurosurgeons' means for practicing in the developing world through a literature review. After this examination of the current funding methods for surgical care in low-income regions, the work transitions to an explanation of the applications and limitations of a new resource: the internal wealth of a developing country. This wealth may be leveraged by way of a for-profit hospital to create sustainable and domestic funding for nonprofit neurosurgical training. The applicability of the proposed mechanism extends beyond the field of neurosurgery to nonprofits in any health-related discipline. Factors influencing the viability of this mechanism (including local disease burden, economic trajectory, and political stability) are examined to create a baseline set of conditions for success.

The association of low birthweight and chronic renal failure among Medicaid young adults with diabetes and/or hypertension.

OBJECTIVE: The purpose of this study was to assess the effect of low birthweight on chronic renal failure among young Medicaid patients with diabetes and/or hypertension. METHODS: The study included Caucasian and African American young adults, aged 18-50, who enrolled in the Medicaid program from 1993 to 1996 in South Carolina and were diagnosed with diabetes and/or hypertension. The odds of chronic renal failure by low birthweight (< 2,500 grams) was estimated using logistic regression. RESULTS: Of the 7,505 Medicaid patients with diabetes and/or hypertension, 179 (2.4%) were diagnosed with chronic renal failure. These patients were younger (mean age of 33.9 vs. 37.6, p = 0.0024) and had a higher proportion of low birthweight (15.1% vs. 11.4%, p = 0.07) compared with the 7,326 patients without renal failure. The odds ratio of chronic renal failure for low birthweight was significantly higher compared with normal birthweight (2,500-3,999 grams) (adjusted odds ratio [OR] 1.56, 95% confidence interval [95% CI] 1.0, 2.4). The association between low birthweight and chronic renal failure was stronger among the 888 patients with both diabetes and hypertension (OR 2.6, 95% Cl 1.3, 5.7) than the 1,812 diabetes or the 4,805 hypertension patients. CONCLUSIONS: The odds of chronic renal failure by low birthweight was highest in patients with both diabetes and hypertension, suggesting that the mechanism(s) involved in the disease progression to chronic renal failure may have a fetal early life origin.

Convection-enhanced delivery of immunotoxins and radioisotopes for treatment of malignant gliomas.

The treatment of malignant gliomas has advanced significantly in the past 15 years. The simultaneous development of new targeting agents and techniques to deliver these high-molecular-weight compounds has led to improved efficacy and promising results in Phase III trials. Convection-enhanced delivery (CED) of macromolecules has emerged as the leading delivery technique for the treatment of malignant gliomas. A summary of the basic principles of CED and a review of the current human trials of protein targeting agents are provided.

Arterial compression of the retro-olivary sulcus of the medulla in essential hypertension: a multivariate analysis.

OBJECTIVE: Pulsatile arterial compression (AC) of the ventrolateral medulla (VLM) has been postulated to cause neurogenically mediated essential hypertension (EHTN). We aimed to establish whether the association between AC of specifically the retro-olivary sulcus (ROS) of the VLM and EHTN was significant, while controlling for other risks associated with EHTN. DESIGN: Case-control study. METHODS: Posterior fossa magnetic resonance imaging scans of 131 subjects, including 58 subjects with EHTN and 73 normotensives, were reviewed to determine the presence of AC in the ROS. The history of other risk factors for EHTN was obtained by reviewing medical records. RESULTS: Multivariate logistic regression analysis of these data shows a significant association between AC in the ROS (right and/or left) and EHTN [odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.30, 7.06]. This analysis was done controlling for other known EHTN risk factors such as age, race, sex, diabetes, and obesity. A secondary analysis also controlling for these variables shows that AC of both the right and left ROS are independently associated with EHTN (right AC: OR = 5.04, 95% CI = 1.33, 19.17; left AC: OR = 3.39, 95% CI = 1.20, 9.60). CONCLUSIONS: In this retrospective study of subjects with EHTN and normotensive controls that had undergone magnetic resonance imaging of the posterior fossa, AC of the ROS on either side of the medulla is a significant independent risk factor in EHTN. Further studies are required to determine whether this is true for the general population of patients with neurogenically mediated EHTN.