High-risk Variables Research Articles

Predicting the unpredictable? Identifying high-risk versus low-risk parents with intellectual disabilities

Objectives This study set out to identify risk factors affecting parents with intellectual disabilities (IDs) by determining: (i) whether perception of family support differs between parents with IDs, referring professionals, and a specialist parenting service; (ii) whether multivariate familial and demographic factors differentiates ‘high-risk’ from ‘low-risk’ parenting; and (iii) the impact of partner relationships on parental competency and risk status. Methods Secondary data analysis was conducted on data gathered from 101 parents with IDs and 172 of their children, all of whom had been referred to a specialist parenting service over a 5 year period. Results Cross-tabulations were applied to the data to examine causal processes and to improve general understanding of the risks associated with families. Contrary to popular expectations IQ levels of the main parent, relationship status, parental age, employment, amenities, valued support and parents’ perception of need were not identified as contributory factors distinguishing ‘high-risk’ from ‘low-risk’ parents. Instead, ‘high-risk’ parenting associated more with parental reports of childhood trauma (emotional abuse and physical neglect in particular), parents’ having additional special needs in addition to their IDs or parents who were raising a child with special needs. Other ‘high-risk’ factors identified related to the male partners of mothers with IDs, many of whom did not have IDs and/or whose histories included anti-social behaviors or criminality. Conclusions The study identified some high-risk variables among parents with IDs that can distinguish them from low-risk parents with IDs. Practice implications These findings generate challenges for agencies who attempt to capture the needs of parents with IDs and who endeavour to provide services to families deemed to be “at risk.” These outcomes will be of special interest to the courts, especially when parents with IDs are involved in care proceedings.

Outcomes after carotid endarterectomy: Is there a high-risk population? A National Surgical Quality Improvement Program report

Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis for symptomatic and asymptomatic patients. Carotid angioplasty and stenting (CAS), however, has been proposed as alternative therapy for patients deemed at high-risk for CEA. This study examined 30-day adjudicated outcomes in a contemporary series of CEAs and assessed the validity of criteria used to define a potential high-risk patient population for CEA. Patients undergoing isolated CEA in private sector hospitals between Jan 1, 2005, and Dec 31, 2006, were identified using the prospectively gathered National Surgical Quality Improvement Program database. The primary study end points were 30-day stroke and death rates. Demographic, preoperative, and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. Variables used to define systemic "high-risk" patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study (active cardiac disease, severe chronic obstructive pulmonary disease, and octogenarian status) were examined individually and in composite fashion for association with study endpoints. Of the 3949 CEAs performed, 59% were in men, 30% were "high-risk" (19% age >80), and 43% had a previous neurologic event. The 30-day stroke rate was 1.6%, the death rate was 0.7%, and combined stroke/death rate was 2.2%. Multivariate analysis showed that intraoperative transfusion (odds ratio [OR], 5.95; 95% confidence interval [CI], 1.71-20.66; P = .005), prior major stroke (OR, 5.34; 95% CI, 2.96-9.64; P < .0001), shorter height (surrogate for small artery size; OR, 1.09; 95% CI, 1.02-1.16; P = .010), and increased anesthesia time (OR, 1.02; 95% CI, 1.00-1.03; P = .008) were predictive of stroke. Critical limb ischemia (OR, 12.72; 95% CI, 3.49-46.40; P < .0001) and poor functional status (OR, 7.05; 95% CI, 2.95-16.82; P < .0001) were independent correlates of death. Systemic high-risk variables, either combined or individually, did not increase risk of stroke or death on multivariate analysis. CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. Anatomic and technical features are the important predictors of perioperative stroke, whereas critical limb ischemia and poor functional status are important predictors of death for patients undergoing CEA. These data refute the concept that CAS is preferred for patients deemed high-risk by virtue of systemic comorbidities.

ICD implantation in patients with ischemic left ventricular dysfunction

Sudden cardiac death (SCD) is responsible for most deaths related to heart disease. Risk stratification in patients with ischemic heart disease can identify patients at increased risk of sudden death who may derive a mortality benefit from an implantable defibrillator. The most commonly used clinical variable for risk stratification and selection of patients for implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden death is left ventricular ejection fraction. Because many sudden deaths occur in patients without common high-risk variables and many patients with ICDs do not receive device therapy, further investigation is warranted to improve risk stratification and patient selection for defibrillator therapy.

Evaluating Common De-Identification Heuristics for Personal Health Information

Background With the growing adoption of electronic medical records, there are increasing demands for the use of this electronic clinical data in observational research. A frequent ethics board requirement for such secondary use of personal health information in observational research is that the data be de-identified. De-identification heuristics are provided in the Health Insurance Portability and Accountability Act Privacy Rule, funding agency and professional association privacy guidelines, and common practice.Objective The aim of the study was to evaluate whether the re-identification risks due to record linkage are sufficiently low when following common de-identification heuristics and whether the risk is stable across sample sizes and data sets.Methods Two methods were followed to construct identification data sets. Re-identification attacks were simulated on these. For each data set we varied the sample size down to 30 individuals, and for each sample size evaluated the risk of re-identification for all combinations of quasi-identifiers. The combinations of quasi-identifiers that were low risk more than 50% of the time were considered stable.Results The identification data sets we were able to construct were the list of all physicians and the list of all lawyers registered in Ontario, using 1% sampling fractions. The quasi-identifiers of region, gender, and year of birth were found to be low risk more than 50% of the time across both data sets. The combination of gender and region was also found to be low risk more than 50% of the time. We were not able to create an identification data set for the whole population.Conclusions Existing Canadian federal and provincial privacy laws help explain why it is difficult to create an identification data set for the whole population. That such examples of high re-identification risk exist for mainstream professions makes a strong case for not disclosing the high-risk variables and their combinations identified here. For professional subpopulations with published membership lists, many variables often needed by researchers would have to be excluded or generalized to ensure consistently low re-identification risk. Data custodians and researchers need to consider other statistical disclosure techniques for protecting privacy.

Severe Post-ERCP Pancreatitis May Become (Almost) Extinct

Prospective studies have defined risk factors for post-ERCP pancreatitis and randomized trials have demonstrated that pancreatic stents reduce the frequency of post-ERCP pancreatitis in high-risk patients. Since then, there has been a need for confirmatory data to establish the value of pancreatic stenting in clinical practice. This prospective study reports the incidence and severity of pancreatitis after ERCP done by a single operator during the last five years. Methods: Data were prospectively collected from 835 consecutive ERCP procedures done during 1999-2003. A subset of patients with high-risk indications included unexplained pancreatitis (N=80) or pain (N=123). Among other reasons, pancreatic stents were placed in patients thought to be at increased risk for pancreatitis after ERCP. Complications and their severity were defined and graded by standard criteria. Results: Sphincter of Oddi manometry (SOM) was attempted in 187 cases (22%). Sphincter of Oddi dysfunction (SOD) was diagnosed in 130 patients (16%); SOM was normal in 43 and failed in 14. Endoscopic therapy was completed in 811 procedures (97%); treatment attempts failed in 11 cases. Access (precut) biliary sphincterotomy was required in 49 cases (6%), 24 of which had pancreatic stents left in place. During another 203 procedures, initial treatment included pancreatic stenting +/- pancreatic sphincterotomy with 29 having stents placed via the minor papilla. The overall complication rate was 3.8%. Post-ERCP pancreatitis occurred in 19 patients (2.3%): mild (N=13), moderate (N=5), and severe (N=1). The only case of severe pancreatitis occurred in a patient with relapsing pancreatitis associated with hypertriglyceridemia who underwent dual sphincterotomy and pancreatic stenting to treat pancreatic SOD. Rates of post-ERCP pancreatitis according to high-risk variables are shown in the table below. Conclusions: 1) Results of this study are similar to those from randomized trials that demonstrated significantly less post-ERCP pancreatitis in the high-risk patients that were treated with pancreatic stents. 2) The frequency and severity of post-ERCP pancreatitis appears to be lower now compared to historical data. Pancreatic stenting is a likely explanation for this decreased risk.

Molecular genotyping of medullary thyroid carcinoma can predict tumor recurrence.

Medullary thyroid carcinoma can have an aggressive behavior, and little is known about the molecular basis for clinical outcome. Defining risk of recurrent or metastatic disease is difficult, and it has been limited to clinical and pathologic features, such as advanced age, cervical lymph node metastases, and stage at presentation. Using microdissection and genotyping, we studied 11 cases of medullary carcinoma for allelic losses in a panel of known tumor suppressor genes. The tumor suppressor genes with the most frequent allelic losses were NF2, l-myc, and p53 (75%, 44%, and 44%, respectively). The average frequency of allelic loss across all tumors was 44% and was higher in tumors that recurred. A combination of previously described high-risk variables (increased patient age and cervical lymph node metastases) with the frequency of allelic loss yielded a high-risk group, in which 6 of 6 patients recurred, and a low-risk group, in which 0 of 5 patients recurred (P = 0.004). Frequency of allelic loss in tumor suppressor genes may provide a useful adjunctive prognostic test in medullary thyroid carcinoma.

Characteristics of mothers of children with fetal alcohol syndrome in the Western Cape Province of South Africa: a case control study.

Factors associated with alcohol consumption during pregnancy and with fetal alcohol syndrome (FAS) births were examined as part of a larger epidemiologic study of FAS in a community in the Western Cape Province of South Africa. Using retrospective case-control methodology, 31 mothers who had given birth to FAS children 6 to 9 years previously were compared with 31 matched controls on a variety of demographic, socioeconomic, drinking, family and maternity variables. Descriptive analyses were utilized to determine major differential characteristics between the two groups. In this community with a very high rate of FAS and rather uniform low socioeconomic status, the two groups were found to be comparable with respect to age, annual income, ethnic background, age of initiation of regular drinking, age at birth of the index child, gravidity and parity. However, mothers of FAS children reported initiating drinking at an earlier age, as well as reporting higher rates of heavy alcohol consumption in their extended family, current use of alcohol, drinking before and during pregnancy, and smoking of tobacco (percentage who smoke) during each trimester of the pregnancy. Mothers of FAS children had lower educational attainment and reported lower religiosity than control mothers. This study in South Africa draws upon the experience of mothers of 31 children with FAS to confirm many of the same high-risk variables identified in maternal risk studies in the United States and Europe. Some factors associated with less maternal alcohol abuse in this high-risk population were also identified, which may be helpful for implementing prevention in this region as well as in other developing countries.

Treatment Outcomes for Students with Learning Disabilities

This study analyzed the magnitude of experimental intervention outcomes as a function of violations in internal and external validity for studies that included students with learning disabilities. The results indicated that treatment outcomes were significantly affected by the following violations: teacher effects, establishing criterion levels of instructional performance, reliance on experimental measures, using different measures between pretest and posttest, using a sample heterogenous in age, and using incorrect units of analysis. Furthermore, the underreporting of information related to ethnicity, locale of the study, psychometric data, and teacher applications positively inflated the magnitude of treatment outcomes. A weighted hierarchical regression analysis revealed that composite scores of the aforementioned high-risk variables accounted for 16% of the total variance in effect size. The implications for interpreting intervention research to practice are discussed.

Sertraline Treatment of Panic Disorder

More than one third of panic disorder patients have a chronic and/or recurrent form of the disorder, accounting for much of the individual and societal cost associated with the illness. Six clinical variables have been most consistently identified as high-risk predictors of poor outcome: (1) panic severity, (2) presence of agoraphobia, (3) comorbid depression, (4) comorbid personality disorder, (5) duration of illness, and (6) female sex. No published research has systematically examined the differential antipanic efficacy of selective serotonin reuptake inhibitors in patients at high risk for poor outcome. Data were pooled (N = 664) from 4 double-blind, placebo-controlled studies of the efficacy of sertraline for the treatment of DSM-III-R panic disorder. Two of the studies were 12-week fixed-dose studies with starting daily doses of sertraline, 50 mg, and 2 were 10-week flexible-dose studies with starting daily doses of sertraline, 25 mg. All other study design features were the same, except for the exclusion of women of childbearing potential in the 2 fixed-dose studies. Exclusion of patients with marked personality disorders and depression meant that only 4 of the poor-outcome variables could be evaluated. Clinical improvement was similar for patients treated with sertraline whether or not they carried an agoraphobia diagnosis, had a duration of illness > 2 years, or were female. Patients with high baseline panic severity had significantly (p = .01) less improvement on the endpoint Clinical Global Impressions-Improvement (CGI-I) scale than patients with moderate severity, although the Clinical Global Impressions-Severity of Illness scale change score was higher in the patients with high severity (-2.00 vs. -1.31). For patients with 3 or more high-risk variables, there was a modest, but statistically significant, tendency for reduced global improvement (endpoint CGI-I score of 2.7 for the high-risk vs. 2.4 for the non-high-risk group; p = .017), although the high-risk group actually had a similar endpoint reduction in frequency of panic attacks (82%) compared with the non-high-risk group (78%). Treatment of panic disorder with sertraline was generally effective, even in the presence of baseline clinical variables that have been associated with poor treatment response. The main limitations of the analysis were the reliance on pooled data from 4 studies (even if the designs were similar) and our inability to examine the impact of depression and personality disorders on response to treatment because of the exclusion criteria of the clinical trials.

Cognitive and behavioural concerns in epileptic children.

Cognitive performance in an epileptic child has been a difficult issue to predict in day-to-day clinical practice. Several observations made in early and later part of this century do not provide uniform and convincing answer to this issue. Recent trends in research however, have identified certain variables that are shown to be associated with cognitive decline in epileptic children. Together with associated behavioural problems, the resultant school difficulty is the essence of this concern for the parents. The variables related to cognitive deterioration as identified by several studies include underlying brain pathology (symptomatic epilepsy), early age of onset of seizure, severity and intractability of seizure, repeated head trauma, an episode of status epilepticus, presence of interictal subclinical EEG discharge, adverse psychosocial factor and antiepileptic drug (AED). Association of these variables in a given case cannot only predict adverse cognition outcome but also a preventive management package can be planned aiming at avoiding or minimizing these high risk variables.

Role of neuropathy and high foot pressures in diabetic foot ulceration.

High plantar foot pressures in association with peripheral neuropathy have been ascertained to be important risk factors for ulceration in the diabetic foot. Most studies investigating these parameters have been limited by their size and the homogeneity of study subjects. The objective of this study was therefore to ascertain the risk of ulceration associated with high foot pressures and peripheral neuropathy in a large and diverse diabetic population. We studied a cross-sectional group of 251 diabetic patients of Caucasian (group C) (n=121), black (group B) (n=36), and Hispanic (group H) (n=94) racial origins with an overall age of 58.5+/-12.5 years (range 20-83). There was an equal distribution of men and women across the entire study population. All patients underwent a complete medical history and lower extremity evaluation for neuropathy and foot pressures. Neuropathic parameters were dichotomized (0/1) into two high-risk variables: patients with a vibration perception threshold (VPT) > or =25 V were categorized as HiVPT (n=132) and those with Semmes-Weinstein monofilament tests > or =5.07 were classified as HiSWF (n=190). The mean dynamic foot pressures of three footsteps were measured using the F-scan mat system with patients walking without shoes. Maximum plantar pressures were dichotomized into a high-pressure variable (Pmax6) indicating those subjects with pressures > or =6 kg/cm2 (n=96). A total of 99 patients had a current or prior history of ulceration at baseline. Joint mobility was significantly greater in the Hispanic cohort compared with the other groups at the first metatarsal-phalangeal joint (C 67+/-23 degrees, B 69+/-23 degrees, H 82+/-23 degrees, P=0.000), while the subtalar joint mobility was reduced in the Caucasian group (C 21+/-8 degrees, B 26+/-7 degrees, H 27+/-11 degrees, P=0.000). Maximum plantar foot pressures were significantly higher in the Caucasian group (C 6.7+/-2.9 kg/cm2, B 5.7+/-2.8 kg/cm2, H 4.4+/-1.9 kg/cm2, P=0.000). Univariate logistic regression for Pmax6 on the history of ulceration yielded an odds ratio (OR) of 3.9 (P=0.000). For HiVPT, the OR was 11.7 (P=0.000), and for HiSWF the OR was 9.6 (P=0.000). Controlling for age, diabetes duration, sex, and race (all P < 0.05), multivariate logistic regression yielded the following significant associations with ulceration: Pmax6 (OR=2.1, P=0.002), HiVPT (OR=4.4, P=0.000), and HiSWF (OR=4.1, P=0.000). We conclude that both high foot pressures (> or =6 kg/cm2) and neuropathy are independently associated with ulceration in a diverse diabetic population, with the latter having the greater magnitude of effect. In black and Hispanic diabetic patients especially, joint mobility and plantar pressures are less predictive of ulceration than in Caucasians.

Risk factors for life-threatening cavopulmonary thrombosis in patients undergoing bidirectional superior cavopulmonary shunt: An exploratory study

We have observed six patients with life-threatening superior vena caval or pulmonary thrombosis after bidirectional superior cavopulmonary shunt. With the use of a case control study we sought to identify perioperative risk factors for this thrombotic complication. Medical records of six patients with cavopulmonary thrombosis and those of 24 patients in a control group were reviewed to abstract data for potential risk factors. Contingency tables and univariate logistic regression were used to determine associations between various perioperative parameters and occurrence of cavopulmonary thrombosis. Preoperative variables associated with thrombosis included bilateral superior vena cavae, odds ratio: 23, p = 0.02, increased age at surgery (p = 0.05), and female sex (odds ratio: 7, p = 0.05). The McGoon Ratio (index of relative pulmonary artery branch diameter) was inversely related to thrombosis risk (p = 0.08). Two torr increases in mean right atrial (p = 0.08) or ventricular end-diastolic (p = 0.05) pressures were associated with approximately 70% increases in thrombosis risk. Intraoperative prolongation of aortic cross-clamp time related directly to thrombosis risk (p = 0.06). Postoperative variables associated with thrombosis included increased superior vena caval pressure within 12 hours after surgery (odds ratio > or = 10 for 5 torr increase in pressure, p = 0.02) and poor ventricular function (odds ratio: 9, p = 0.06) We conclude that high risk variables for patients undergoing a cavopulmonary shunt include bilateral superior vena cavae, female sex, increasing age, decreased McGoon Ratio, and elevated right atrial and ventricular end-diastolic pressure (before surgery), patients with prolonged aortic cross-clamp time (during surgery), and patients with elevated superior vena caval pressure and poor ventricular function (after surgery).

Brief structural/strategic family therapy with African and Hispanic high-risk youth

Brief Strategic/Structural Family Therapy was implemented as an indicated prevention intervention to reduce the likelihood that African American and Hispanic youth initiated drug use. The intervention was designed to impact two important risk factors for initiation, namely behavior problems and poor family functioning. One hundred twenty-two youth, 12–14 years of age and exhibiting behavior problems, were assigned within a basic one-group pretest/posttest/follow-up design. The first important finding was that the prevention intervention was effective in significantly modifying both high-risk factors, reducing behavior problems [F(2, 120) × 32.92; p < .000] and improving family functioning [F(1, 121) × 41.8; p < .000]. A second important finding was that both high-risk variables targeted were statistically significant predictors of initiation nine months later. A third important finding was that for a small subset of youth who entered the program already using, overall use was significantly decreased [t(22) × 2.11, p < .05]. © 1997 John Wiley & Sons, Inc.

Changing characteristics and in-hospital outcome in patients admitted with acute myocardial infarction. Observations from 1982 to 1994.

During the past decade, various new treatments have become available for patients with acute myocardial infarction. The effects of these treatment modalities have been studied extensively in selected patient groups. These studies indicate that early diagnosis, risk stratification and prompt initiation of treatment are of crucial importance for optimal benefit. However, it is not known whether prognosis changed in all patients admitted with an acute myocardial infarction. Also, the characteristics of the infarct population may have changed over time because of new medication regimens, invasive interventions and awareness of the importance of risk factors. We studied all patients admitted with acute myocardial infarction in 1982, 1988 and 1994. Information on baseline characteristics, clinical variables and all interventions was collected. In those 3 years 223, 227 and 235 patients were admitted because of an acute myocardial infarction. Patients admitted in 1994 were older, more often female and less often had a previous cardiac history. More patients admitted in that year had previous balloon angioplasty and coronary bypass grafting. Smoking habits decreased during the past decade. In-hospital mortality was 38 (17%) in 1982, 23 (10%) in 1988 and 22 (9%) in 1994 (P < 0.05). Variables related to high risk for in-hospital death in 1982 were higher age, low systolic blood pressure, atrial fibrillation, absence of accelerated idioventricular rhythm, sustained ventricular tachycardia and signs of left ventricular dysfunction; in 1988 the occurrence of non-sustained ventricular tachycardia, Killip class more than I, the absence of thrombolytic therapy, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting were independently related to in-hospital death. In 1994, high risk variables for in-hospital death were dyspnoea on admission, sustained ventricular tachycardia, female gender, higher creatinine on admission, and a previous cardiac history. In-hospital mortality for unselected patients admitted with an acute myocardial infarction decreased between 1982 and 1988 and remained the same between 1988 and 1994, in spite of further ageing of the population. In the study period there has been a change in baseline characteristics and high risk variables for in-hospital death after myocardial infarction.

What does “high risk” mean? A PsycINFO scan of the literature

Recent health research has emphasized the study of high risk variables without consensus regarding different meanings of the term high risk. We provide a categorization scheme for this concept that includes prediction of consequence variables from antecedent variables in different contexts. Different antecedent-consequence combinations (notions of high risk) across a variety of health research contexts are described based on a search of PsycINFO entries from 1985 to 1990. Investigators apparently limit their notions of high risk by specific research areas. We discuss the potential usefulness of the category scheme for providing a conceptual framework which bridges different research domains, or at least reduces the likelihood of misuse of the term.

Length of Hospital Stay and Complications After Percutaneous Transluminal Coronary Angioplasty

Background Although several studies have established that the complications of percutaneous transluminal coronary angioplasty (PTCA) are related to clinical and angiographic variables such as advanced age and lesion complexity, it is uncertain whether the use of hospital resources after PTCA also depends on the same baseline variables. The purpose of this study was to identify the factors responsible for prolonged hospital stay after PTCA. Methods and Results The study cohort included 591 consecutive patients undergoing conventional balloon angioplasty at nine medical centers in North America. Major or minor complications occurred in 91 patients (15.4%) and were observed to be related to several baseline characteristics, including unstable angina, multivessel coronary artery disease, patient age, and lesion complexity. Compared with a median length of hospital stay of 2.0 days after PTCA (25th, 75th percentiles: 2.0, 4.0) for the entire cohort of patients, the length of stay was increased in patients with unstable angina (3.0 days [2.0, 5.0]; P =.002), multivessel coronary artery disease (3.0 [2.0, 5.5]; P =.001), age &gt;65 years (3.0 [2.0, 5.5]; P =.02), complex lesions (3.0 [2.0, 6.0]; P =.001), and filling defects (6.0 [2.0, 11.0]; P &lt;.001). The length of stay was more strikingly increased, however, in patients who experienced major or minor PTCA complications, such as emergency bypass surgery (9.0 days [8.0, 18.0]; P &lt;.001), Q-wave or non–Q-wave myocardial infarction (8.0 [6.0, 15.5]; P &lt;.001), transfusion unrelated to bypass surgery (8.0 [4.0, 12.0]; P &lt;.001), or abrupt vessel closure (6.0 [3.0, 10.5]; P &lt;.001). On stepwise multiple linear regression, PTCA complications appeared to be the strongest predictors of length of hospital stay (all P &lt;.001) and overwhelmed the weaker relation between length of stay and several individual baseline variables. Inclusion of a composite clinical risk score (reflecting the presence of unstable angina, multivessel disease, advanced age, complex lesions, or filling defects) in the regression model confirmed that patients with several high-risk baseline variables had a significant increase in length of stay after PTCA ( P =.003), but PTCA complications remained the strongest predictors of length of stay. Conclusions Although PTCA complications were correlated with baseline variables such as unstable angina, multivessel disease, advanced age, complex lesions, and filling defects, excess length of stay after PTCA was most strongly influenced by the development of minor and major PTCA complications. Because patients with several baseline risk factors experienced significantly prolonged hospitalizations, improved selection of patients may contribute to reductions in length of stay after PTCA. A greater reduction in resource use after PTCA, however, would be expected from developing new treatments to decrease PTCA complications rather than limiting the access of patients with unstable angina, advanced age, or complex lesions to PTCA.

INCARCERATION AND HIV RISK BEHAVIORS AMONG INJECTION DRUG USERS: A MIDWESTERN CASE STUDY

ABSTRACT Recent statistics indicate that injection drug users (IDUs) and crack cocaine users are increasingly coming into contact with the criminal justice system. A number of these individuals engage in high risk behaviors associated with the transmission of the AIDS virus. This study examines the relationship between level of HIV risk behavior and history of exposure to jail or prison using a sample of 879 midwestem, not-in-treatment IDUs. A number of HIV high-risk variables were found to be significantly related to the IDUs’ time in jail, including: (1) initiation to drug injection at an early age, (2) having multiple sex partners, (3) having a history of an STD, (4) being a daily drug user, (5) daily injection of cocaine, heroin, or speedball, (6) inconsistent use of condoms, and (7) using rented needles. Our data indicate that active IDUs with the highest HIV risk behaviors were those most likely to spend time in jail. Because it reaches a large number of at-risk IDUs, the criminal justice system app...

Relationship of maternal substance abuse to subsequent sudden infant death syndrome in offspring

To assess the possible relationship between maternal drug use during pregnancy and subsequent sudden infant death syndrome (SIDS), we identified 1760 cases of SIDS from a population of more than 1.2 million infants (1.45/1000) born in New York City between 1979 and 1989. The SIDS rate in drug-exposed infants was 5.83 per 1000 infants, compared with 1.39 per 1000 infants who were not drug exposed. With control for known associated high-risk variables, the risk ratio for SIDS in each individual drug group (methadone, 3.6; heroin, 2.3; methadone and heroin, 3.2; cocaine, 1.6; cocaine and methadone or heroin, 1.1) was higher than in the non-drug-exposed group. Higher rates of SIDS were found in infants exposed to opiates alone than in cocaine-exposed infants, but increasing rates of SIDS in cocaine-exposed infants toward the end of the decade suggested that "crack" cocaine may be linked to these increasing rates. Declines in the overall rate of SIDS during the decade were observed for both the drug-exposed (11.28 to 4.09 per 1000) and the nonexposed groups (1.70 to 1.05 per 1000). Differences in rates of SIDS between major racial-ethnic groups in nonexposed infants were not apparent if the mothers used drugs during pregnancy. Seasonal variation and distribution of ages at time of SIDS death did not differ between the drug-exposed group and the nonexposed group, suggesting that drug-associated SIDS may provide clues as to the cause or causes of SIDS.

2. Assessment of the problem, pathology, and risk factors for disability

Abstract This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article covers ergonomic assessment of upper limb and low back injury, medical diagnostics for upper extremity cumulative trauma disorder (UE-CTD) and low back pain, and an evaluation of delayed recovery following work injury. Advances that are covered in this article involve factors contributing to UE-CTD, lumbar spine-imaging techniques, and the high-risk variables that contribute to prolonged disability.

Complications of pregnancy and delivery in relation to psychosis in adult life: data from the British perinatal mortality survey sample.

To evaluate whether events occurring at or around the time of birth contribute to the onset of psychotic illness in adult life. DESIGN-Pregnancy and birth complications as possible causes of adult mental illness were studied in the population sample of the British perinatal mortality survey. Subsequent psychiatric admissions were independently identified through the Mental Health Enquiry and records of regional and special health authorities. Logistic regression was used to compare data on perinatal deaths with those on survivors to determine factors independently associated with perinatal death, and this equation was then used to calculate the risk of perinatal death for each survivor. 16,980 people born in a single week in 1958 (the British perinatal mortality survey sample), including 252 patients admitted to psychiatric care; case notes of 235 patients were supplied. Patients with a schizophrenic illness (whether defined by "broad" (n = 57) or "narrow" (n = 35) diagnostic criteria) did not have a greater mean risk of perinatal death than the population in general, but there was some evidence of increased liability (relative risk 2.43; 95% confidence interval 1.17 to 5.05) for those with affective psychosis (n = 32). Specific high risk variables for affective psychosis were decreased gestation time (273.9 v 281.2 days; mean difference 7.3 days, 95% confidence interval 3.1 to 11.5; p less than 0.002) and prescription of vitamin K to the child in the first week of life (19% of patients v 5% of controls, p = 0.016). The findings give no support to theories that factors predicting perinatal mortality contribute significantly to causation of schizophrenic illness. Further investigation of decreased gestation length in relation to affective disorder is required.