Initiation Of Preventive Measures Research Articles

National Long-Term Follow-up of Children with Sickle Cell Disease Diagnosed By Newborn Screening in the Netherlands: Overview of the Morbidity and Mortality

Background: Sickle cell disease (SCD) is a genetic red blood cell disorder associated with increased morbidity and mortality. Newborn screening for SCD was introduced in January 2007 in the Netherlands to enable early diagnosis and initiation of preventive measures. The objective of this study was to assess the effect of newborn screening on the morbidity and mortality of children living with SCD in the Netherlands, 16 years after its implementation. Methods: In this national cohort study all children with SCD diagnosed by newborn screening were included. Patients were followed between 1 January 2007 and 31 March 2023 until end of follow-up, death or successful stem cell transplantation. Following informed consent, data were collected from medical files on SCD genotype, treatment, mortality and development of SCD-related complications. The incidence rate of SCD-complications was presented as lifetime-event per 100 person-years for the total duration of follow-up and for the age categories: 0-4, 5-11, and 12-16 years. Results: In total, 391 out of 540 eligible patients (72%) with SCD were included in all hospitals with patients with SCD under treatment, accounting for 3047 person-years. The mean age at the end of follow-up was 7.8 years (SD±4.5). The majority of patients had SCD genotype HbSS (58%), followed by HbSC (28%). As for the mortality, five patients died during follow-up, primarily at or below the age of 2 years (4/5, 80%). In three patients, the cause of death was related to SCD, including infection (n=2; aged 1.2 and 2.0 years) and acute splenic sequestration (n=1; 2.0 years). The SCD-related complications are presented in Table 1. The most common SCD complication in this cohort was vaso-occlusive crisis (including dactylitis) with hospitalization. SCD-related complications that mainly developed within the first 4 years of life, were vaso-occlusive crisis, acute hemolytic crisis, aplastic crisis, severe infections, splenic sequestration and ischemic cerebral infarction. Acute chest syndrome occurred equally in all age categories. Other SCD-related complications developed to a lesser extent in our cohort, and at a later age in adolescence or adulthood. Conclusion: In this cohort of neonatally screened children with SCD, a substantial number of SCD-complications occurred in the first 4 years of life. This study underlines the importance of parental education and 24/7 availably, high level acute specialized clinical care for these children from birth on. Further analysis to identify risk factors at young age for a severe phenotype will be conducted, to enable more targeted interventions in a timely manner. Hopefully, this will lead to reduction of disease burden, improving the quality of life in children living with SCD in the Netherlands.

ПРОФИЛАКТИКА АТОПИЧЕСКОГО ДЕРМАТИТА С УЧЕТОМ ПАТОГЕНЕЗА ЗАБОЛЕВАНИЯ

Atopic dermatitis (AD) is a multifactorial chronic skin disease that onsets at an early age. The AD prophylaxis is extremely important because of the high risk of development of allergic rhinitis and bronchial asthma later on. The authors present an overview of the mechanisms of the AD development. The significance of congenital factors predisposing to the AD substantiates the earliest possible initiation of preventive measures, especially in families with a positive history of atopy. The modern measures for AD prevention are based on the pathogenetic mechanisms of the disease. One of the effective preventive measures is the use of emollients.

Prevalence of overweight and obesity among rural school children aged between 6 years to 16 years

Background: The rise of childhood overweight and obesity in India is not only restricted to urban localities but fast spreading to rural areas due to lifestyle change and economic transition. Effective preventive measures will prevent the risk of developing chronic diseases like diabetes, hypertension etc., in adult life. This study aimed at assessing the prevalence of overweight and obesity and estimate the various factors influencing on it among school children in rural area.Methods: A cross-sectional study was conducted among 542 school children of age 6-16 years from selected schools of B. G. Nagara. Research tool comprised of questions about demographic characteristics, type of physical activity, screen time, height and weight were measured on calibrated scales and BMI was assessed using IAP-growth charts. Statistical analysis was done using statistical package for social sciences (SPSS) 22 version statistical software.Results: Overall, the prevalence of overweight and obesity was 12.9% and 7% respectively. The prevalence of overweight was more in girls (13.6%) than boys (11.3%), whereas the prevalence of obesity was more in boys (8.2%) than girls (5.6%). Association of overweight and obesity with socio-economic status, parental obesity, type of food consumption, screen time, daily physical activity in children revealed a strong statistically significant correlation (p<0.001).Conclusions: The prevalence of overweight is higher than obesity with statistically significant correlation with various factors, revealing the need for public awareness and initiation of preventive measures for development of obesity and the complications related to it.

Cardiac Cachexia: Unaddressed Aspect in Cancer Patients.

Tumor-derived cachectic factors such as proinflammatory cytokines and neuromodulators not only affect skeletal muscle but also affect other organs, including the heart, in the form of cardiac muscle atrophy, fibrosis, and eventual cardiac dysfunction, resulting in poor quality of life and reduced survival. This article reviews the holistic approaches of existing diagnostic, pathophysiological, and multimodal therapeutic interventions targeting the molecular mechanisms that are responsible for cancer-induced cardiac cachexia. The major drivers of cardiac muscle wasting in cancer patients are autophagy activation by the cytokine-NFkB, TGF β-SMAD3, and angiotensin II-SOCE-STIM-Ca2+ pathways. A lack of diagnostic markers and standard treatment protocols hinder the early diagnosis of cardiac dysfunction and the initiation of preventive measures. However, some novel therapeutic strategies, including the use of Withaferin A, have shown promising results in experimental models, but Withaferin A’s effectiveness in human remains to be verified. The combined efforts of cardiologists and oncologists would help to identify cost effective and feasible solutions to restore cardiac function and to increase the survival potential of cancer patients.

Современные подходы к диагностике острого повреждения почек с применением инновационных биомаркеров у пациентов с сочетанной травмой: обзор научных публикаций

A review of scientific publications analyzing modern approaches to the diagnosis of acute kidney injury using innovative biomarkers in patients with concomitant trauma is presented. The authors of the review note that pathological processes of cellular damage, which determine the etiology and pathogenesis of acute kidney injury syndrome, require prompt and early initiation of preventive measures. Given this, the problem of early diagnosis of acute kidney injury and the scientific search for ways to optimize it remain relevant at the present time. In cases associated with the possibility of formation of acute kidney injury, as well as in situations when the renal tissue is already damaged, it is very relevant to determine markers of acute kidney injury in biological fluids.

Field Therapy in Solid Organ Transplant Recipients: Are We Initiating Early Enough?

Organ transplant recipients (OTRs) are at increased risk for more aggressive non-melanoma skin cancer (NMSC). Recent emphasis on field therapy has complimented the canonical surgical treatment paradigm. This retrospective analysis of survey responses by patients seen at Oregon Health and Science University from 2013-2018 offers insights into patient trends and practice gaps in caring for OTRs. All patients completed a 57-point questionnaire at their first clinic visit, which included questions regarding demographics, transplant history, dermatologic history, and use of field therapy. Of the 295 patients (mean age, 56 years; M/F: 193/102) who completed the questionnaire, field therapy was reported by 31 (11%) patients. Field therapy patients noted an overall higher AK and SCC burden, with a greater proportion of patients reporting >20 AKs and >10 SCCs. Field therapy use was sparse in the low AK/low SCC group (n=25) when compared to those reporting high AK/high SCC (n=11) burden (n=4 (16%) vs n=8 (73%), P<0.01). This data suggests that OTRs with several clinically evident AKs and/or a low number of SCCs are less likely to have been treated with field therapy modalities compared to OTRs who have developed >10 AKs or ≥6 SCCs. A delay in initiation of preventative measures or field therapy in this population, however, may be a missed opportunity for intervention. Early intervention with field therapy in particularly high-risk OTRs with a low skin cancer burden may mitigate future skin cancer development.J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4759.

P2488The 2013 ACC/AHA pooled cohort equations and insulin resistance status for detection of early-stage heart failure in the community

Abstract Objectives Detection of heart failure (HF) in its subclinical phase would allow timely initiation of preventive measures that counter its pathophysiology. Here, we assessed the usefulness of traditional cardiovascular (CV) risk assessment and insulin resistance status to detect early-stage HF. Methods In 984 participants (mean age, 57.0 years, 52.3% women), we derived echocardiographic indexes of left ventricular (LV) structure and function and calculated the 10-year risk for a first atherosclerotic CV disease (ASCVD) using the 2013 ACC/AHA risk score. We assessed the discriminatory value of this risk score to detect LV maladaptation and the improvements in reclassification by insulin resistance status (HOMA-IR). Results The probability for LV maladaptation rose progressively with the 10-year ASCVD risk increasing. Participants at high 10-year ASCVD risk (>7.5%) had indeed significantly higher odds for LV concentric remodeling (odds ratio, 4.84), LV hypertrophy (OR, 5.93), abnormal LV longitudinal strain (OR, 2.04) and LV diastolic dysfunction (OR, 25.3) as compared to those at low ASCVD risk (<2.5%; P≤0.0003). Adding markers of insulin resistance to the ACC/AHA risk score moderately improved the integrated discrimination and net reclassification of all LV maladaptive phenotypes (P≤0.022) except LV diastolic dysfunction (P≥0.059). LV remodeling and abnormal LS was particularly more likely in insulin-resistant participants with a 10-year ASCVD risk between 5% and 15% than in their insulin-sensitive counterparts. Prediction of early-stage HF profiles 2013 ACC/AHA risk score Addition of insulin resistance status to the 2013 ACC/AHA risk score AUC (95% CI) Integrated Discrimination Improvement Net Reclassification Improvement Absolute IDI (%) P value NRI (95% CI) P value LV concentric remodeling 0.70 (0.66 to 0.74) 0.0083 (11.3%) 0.022 0.23 (0.067 to 0.39) 0.0058 LV hypertrophy 0.70 (0.66 to 0.74) 0.017 (20.7%) 0.0033 0.27 (0.11 to 0.43) 0.0011 Abnormal LV LS 0.56 (0.53 to 0.62) 0.022 (202.0%) <0.0001 0.33 (0.18 to 0.49) <0.0001 LV diastolic dysfunction 0.82 (0.78 to 0.86) 0.0007 (0.45%) 0.84 0.093 (−0.11 to 0.30) 0.38 ≥2 LV abnormalities 0.76 (0.72 to 0.80) 0.0087 (7.3%) 0.071 0.22 (0.042 to 0.40) 0.016 The integrated discrimination improvement (IDI) and net reclassification improvement (NRI) reflect the improvements in classification by adding insulin resistance (by HOMA-IR) to the 2013 ACC/AHA risk score. HOMA-IR, Homeostatic Model for Assessment of Insulin Resistance; LS, longitudinal strain; LV, left ventricular. Risk enhancers of LV maladaptation Conclusions The 2013 ACC/AHA risk score adequately captured the risk for echocardiographic phenotypes of early-stage HF. As risk enhancer, insulin resistance might improve risk stratification of subclinical HF in subjects at intermediate risk. Acknowledgement/Funding The European Union, European Research Council and the Flanders Scientific Research Fund supported this study.

Tackling the Opioid Epidemic: Using the Enhanced Recovery After Surgery Principles to Manage Gynecological Post-Op Pain

Since the 1990s, the opioid epidemic has had detrimental consequences including unnecessary prescriptions, misuse leading to addiction, and death from withdrawal symptoms. In the last few years, there has been an increase in awareness of this crisis and a call for solutions 1. On October 2, 2018 California’s Controlled Substance Utilization Review and Evaluation, better known as CURES 2.0 was implemented. Essentially, before prescribing federally controlled substances such as narcotics, health professionals must first look up a patient’s prescription history in the CURES data base. This program was established with the intention of decreasing abuse and diversion of addictive medications without effecting patient care and management 2. While this database is a step in the right direction, I believe initiation of preventive measures can have more of a lasting effect and eliminate the need for initial opioid prescription, the preceding factor to the list of negative outcomes mentioned above.

1549. Development and Validation of a Cycle-Specific Risk Score for Febrile Neutropenia After Chemotherapy in Patients with Cancer: The CSRFENCE Score

BackgroundPrediction of febrile neutropenia (FN) with initiation of preventive measures in high-risk populations may lead to better outcomes in cancer treatment. We have previously developed a score to predict FN in the first cycle of chemotherapy.1 We aimed to develop and validate a cycle-specific score to predict FN in cycles two to six as guidelines recommend assessing the risk of FN at each cycle start.MethodsWe included consecutive patients with solid cancers at Rigshospitalet, University of Copenhagen, 2010–2016. FN was defined as neutrophils <0.5 × 109/L or leukocytes ≤2.0 × 109/L at the time of either a blood culture sample or death. Predictors of FN were analysed using Poisson regression adjusted for repeated measurements using 2:1 random split sampling. Risk factors assessed were: FENCE risk groups,1 sex, body surface area, Charlson Comorbidity Index score, haemoglobin, leukocyte and platelet levels, chemotherapy drugs, radiotherapy, prophylactic granulocyte colony-stimulating factors (G-CSF), previous FN or neutropenia, dose delays, dose reductions, and cycle number. Parameter estimates were scaled and summed to create the risk score.ResultsThere were 324 FN events among the 4,590 patients in the derivation cohort with a median 3 (IQR 2–5) chemotherapy cycles. The FENCE risk groups1 (0/+25/+25/+30 points for low/intermediate/high/very high risk), anaemia (+15 points), chemotherapy drugs (+9/+11 for platinums/taxanes), concurrent radiotherapy (+19 points), prophylactic G-CSF (−14 points), previous FN or neutropenia (0/+19/+43/+59 points for no neutropenia/neutropenia/1 FN event/>1 FN event in previous cycles), and cycle number (0/−9/−11/−12/−19 points for cycle 2/3/4/5/6) predicted FN. Discrimination of the CSRFENCE score was good with a Harrell’s C-statistic of 0.79 (95% CI 0.77–0.82) and similar in the validation cohort (Table 1). Numbers needed to treat with G-CSF to avoid one FN event over 21 days were 748, 121, and 34 in the low-, intermediate-, and high-risk groups, respectively. ConclusionWe developed and validated a risk score to predict FN in cycles two to six of chemotherapy. The CSRFENCE score provides good differentiation of risk groups but needs validation.Reference1. Aagaard et al. Poster 2352. IDWeek; 2017; San Diego, CA.Disclosures L. Specht, Takeda: Investigator and Scientific Advisor, Consulting fee and Research support; Merck: Scientific Advisor, Consulting fee; Varian Medical Systems: Research agreement, Research grant; Merck Serono: Research agreement, Research support; Nanovi: Investigator, Consulting fee and Research support.

Age‐ and Occupation‐Based Public Health Considerations Related to Osteoarthritis of the Knee Joint: A Cadaveric Study.

ObjectiveOsteoarthritis (OA) literature makes minimal suggestion regarding age of disease onset or preventative strategies to reduce risk for onset in various populations. In 2005, the Center for Disease Control and Prevention estimated that 33.6% of Americans 65+ years old were affected by OA; this cadaveric analysis suggests this is largely underestimated. The objective of this assessment is to identify at‐risk populations for OA in the knee joint and make recommendations to prevent or delay disease onset.DesignMorphometric analyses of the articular cartilage of the tibial plateau were performed on cadaver specimens using Image ProÒ software on three age populations and surface area measurements for articular cartilage degradation were compared to donors' reported ages, clinical histories and occupations.ResultsData showed that by the 7th decade of life, when patients are in their 60s, articular cartilage degeneration on the tibial plateau had commenced in 100% of specimen. All “homemakers” displayed above average medial tibial plateau degeneration (32.33 ± 24.85%) for their age group while simultaneously reporting pathologies in their clinical history that encourage a sedentary lifestyle. Atrophy or degeneration of crucial ligaments supporting the knee can encouraging sheering and cartilage degeneration. Cadaver knee specimens in the 70–79 years old age group displayed a 10.5% decrease in average ACL circumference (mm) compared to the group of &lt;70 years old specimens (P &lt; 0.001).ConclusionsThis assessment identifies an occupational class with a propensity to develop disease and also identifies a more realistic time frame than previous advisory committees have produced regarding age of disease onset and initiation of preventative measures. Especially given the ACL thins with aging, it is recommended that strengthening of the hip abductors and the musculature supporting the knee commence early in adult life to avoid valgus collapse and shearing at the knee joint.Support or Funding InformationInternal Grant from Rocky Mountain University of Health ProfessionsThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Age- and Occupation-Based Public Health Considerations Related to Osteoarthritis of the Knee Joint: A Cadaveric Study

Osteoarthritis (OA) literature makes minimal suggestion regarding age of disease onset or preventative strategies to reduce risk for onset in various populations. In 2005, the Centers for Disease Control and Prevention estimated that 33.6% of Americans 65+ years old were affected by OA; this cadaveric analysis suggests this is largely underestimated. The objective of this assessment is to identify at-risk populations for OA in the knee joint and make recommendations to prevent or delay disease onset. Morphometric analyses of the articular cartilage of the tibial plateau were performed on cadaver specimens using Image Pro software on 3 age populations and surface area measurements for articular cartilage degradation were compared with donors' reported ages, clinical histories, and occupations. Data showed that by the seventh decade of life, when patients are in their 60s, articular cartilage degeneration on the tibial plateau had commenced in 100% of specimen. All "homemakers" displayed above-average medial tibial plateau degeneration (32.33% ± 24.85%) for their age group while simultaneously reporting pathologies in their clinical history that encourage a sedentary lifestyle. This assessment identifies an occupational class with a propensity to develop disease and also identifies a more realistic time frame than previous advisory committees have produced regarding age of disease onset and initiation of preventative measures. It is recommended that strengthening of the hip abductors and the musculature supporting the knee commence early in adult life to avoid valgus collapse and shearing at the knee joint.

Prevalence of temporomandibular disorders in Chennai population

Objective: This study aimed to determine the prevalence of temporomandibular disorders (TMDs) in Chennai city population. Materials and Methods: To obtain a representative sample, a house-to-house survey was conducted in three zones of Chennai and a total of 4197 individuals were randomly selected for the study. Among 4197 individuals, 1158 were excluded from the study, based on the exclusion criteria. Finally, a total of 3039 individuals were included in the study population. Results: More than half of the study sample (53.7%) in the present study had one or more clinical signs and symptoms of TMD. Deviation of mandible on mouth opening (42.1%) and clicking sound (38.6%) made up the highest percentage. Females aged 18 years and older reported higher prevalence of TMD signs and symptoms than men. However, these differences were not significant for all signs and symptoms in all age groups. Prevalence of TMD was reported in this study according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) system of classification, and myofacial pain dysfunction syndrome (MPDS) was reported in 0.8% of the population, internal derangement in 38.3%, and osteoarthritis in 14.6% of the population. Conclusion: Our study, in comparison to other prevalence studies, had a higher sample size and was representative of a cross section of the population. The results of this study show that a significant percentage of the population has signs of TMDs and there are chances that they may develop symptoms of TMDs. Further studies are needed for early identification and initiation of preventive measures which could prevent TMDs progressing to advanced stages where management becomes difficult.

Assessment of insulin resistance in normoglycemic young adults

Detection of Insulin resistance (IR) in normoglycemic young subjects before the onset of Impaired Glucose Tolerance (IGT) is of importance as it affords implementation of preventive measures in such high risk subject. Very few studies have specifically evaluated for the presence of IR in younger age group with normal glucose tolerance. The gold standard for investigating and quantifying insulin resistance is the "hyperinsulinemic euglycemic clamp," the complicated nature of the "clamp" technique, alternatives have been sought to simplify the measurement of insulin resistance. The oral glucose tolerance test (OGTT) is one of the most commonly used methods to evaluate whole body glucose tolerance in vivo. IR & IS values of HOMA-IR, ISI 0-120, QUICKIE mathematical models derived from OGTT have been shown to produce equivalent results as in Euglycemic clamp technique we hypothesized that normoglycemic young adult who are siblings of type II diabetics (SD) probably have higher IR values than the siblings of non diabetics as they are genetically predisposed. In this study 79 normal young adult volunteers, 40 subjects with family history of diabetes (SD) and 39 subjects without family history of diabetes (SND), in the age range of 18 to 25 years were evaluated for Insulin resistance. Standard (75 g) OGTT was performed on all the study subjects after an overnight fast. Fasting (basal), 30, 120 min venous plasma glucose & Corresponding specific insulin concentration was determined by radioimmuno assay (RIA) using a human specific antibody RIA kit. In each subject, the degree of insulin resistance was estimated by various parameters of Insulin resistance & sensitivity that were calculated using physiological mathematical models like HOMA-IR, ISI0-120, IGI, QUICKIE and their formulas derived from OGTT. The mean age of the study population was 19.01 (18 to 25 years), Male: 33 (41.3%) and Female: 47 (58.8%). The normoglycemic subjects were categorized as Siblings of Diabetics (SD n = 40) and siblings of non-diabetics(SND n = 39). Both the groups were matched by physical, clinical and routine laboratory parameters and were not statistically significant different. Siblings of diabetics had a statistically significant higher values of insulin at baseline, 30 min & 120 minutes and glucose at 30 minutes. Siblings of diabetics had a significantly higher insulin resistance and lower insulin sensitivity indices as in HOMA-IR (2.01527, p < 0.017), ISIO-120 (56.27, p < 0.002) and I0/G0 ratio (0.122381, p < 0.012) and a trend towards significance for QUICKIE(0.29578, p < 0.056). Detection of insulin resistance in normoglycemic young adult subjects in pre-disease state is feasible using mathematical models like HOMA IR, ISIO-120 from OGTT. OGTT is simple and a generally acceptable test. Siblings of diabetics had higher Insulin resistance values and lower Insulin sensitivity values. Physiological models like HOMA IR, QUICKIE, I0/G0 ratio, IGI, ISIO-120 are simple & cost effective method for screening Insulin resistance. Diagnosis of Insulin resistance in pre-disease state allows initiation of preventive measures like life style modification, diet & exercise, thereby preventing the high risk subjects from progressing to disease state.

Pulse Pressure and Arterial Compliance Prior to Pregnancy and the Development of Complicated Hypertension During Pregnancy

We examined the relationship between prepregnant pulse pressure (PP), mean arterial pressure (MAP), cardiac output (CO)/PP, a measure of arterial compliance, and development of complicated hypertension (CH) during pregnancy with the goal of identifying a potential predictor of CH. Twenty nulliparous participants were studied before pregnancy; 17 had normal pregnancies (control; CTL) and 3 CH. Blood pressure monitoring was performed using tonometry. Cardiac output was determined by Doppler echocardiograph. Data are expressed as mean +/- SD. Prepregnant PP was significantly higher in CH participants (CH: 58.3 +/- 6.3, CTL: 46.2 +/- 1.7 mm Hg; P = .02). Cardiac output /pulse pressure was significantly lower in CH participants (CH: 6.9 +/- 1.8, CTL: 10.6 +/- 2.8; P = .04). Mean arterial pressure was not significantly different. Increased PP before pregnancy may suggest increased risk for CH. With accurate prediction of CH before pregnancy, initiation of preventative measures could begin earlier, either prior to or in early pregnancy, potentially increasing preventative efficacy and decreasing CH.

Akutes Nierenversagen

Previously often regarded as only simple organ dysfunction which can easily compensated by modern renal replacement therapies, acute kidney injury (AKI) has lately been recognized as systemic proinflammatory, pro-oxidative syndrome, which independently from the severity of the underlying disease, exerts a fundamental impact on the course of disease, the evolution of complications, and outcome. Patients do not only die with but also from AKI. The causes of this fundamental impact of AKI on the course of disease and prognosis are based on the fact that AKI not only results in the well-known effects on volume and electrolyte balance but affects all biological functions and organ systems. AKI augments any inflammatory reaction, which results in distant organ injury of nonrenal organs, such as the lung, the heart, or the liver. Immunocompetence is massively compromised in AKI patients, and infections represent the most important cause of death in this patient group. These negative effects of AKI are mediated by three interrelated mechanisms: by acute uremic intoxication per se, by activation of cellular elements and release of cytokines by the injured kidney (the kidney as the "offender"), and by side effects caused by the type and intensity of renal replacement therapy. Because of the profound impact of AKI on the course of disease on short- and long-term prognosis, early diagnosis and initiation of preventive measures is of outmost importance to avoid the evolution of AKI. If AKI had become manifest, renal replacement therapy has to be adapted - regarding the optimal treatment modality, the timing, and therapy dose - in such manner as to minimize the negative side effects of AKI on the organism. Unfortunately, even modern renal replacement therapies are not able to simulate the complex renal functions and to fully compensate for the negative impact of AKI.

How to Identify the Asymptomatic High-Risk Patient?

Worldwide, cardiovascular diseases are among the leading causes of mortality and morbidity with ever-increasing prevalence. Early targeted initiation of preventive measures would be of great benefit and can provide a major opportunity in reducing mortality and morbidity. To this end, accurate identification of individuals who are still asymptomatic but at elevated risk is essential. However, traditional risk assessment fails to recognize a substantial proportion of patients at high risk while a large proportion of individuals are classified as having intermediate risk, leaving management uncertain. Additional strategies to further refine risk assessment are therefore highly needed. To this end, the use of biomarkers and noninvasive imaging modalities has been proposed. The aim of this review is to provide an overview of the different approaches that are available or under development to improve the identification of asymptomatic individuals at elevated risk for cardiovascular diseases events.

A Case Report of Bilateral Autoenucleation and Its Prevention

Purpose: To report a case and review both the ophthalmic and psychiatric literature to document the pattern of this self-mutilation and review prevention techniques. Design: Case report and retrospective review. Interventions: Surgical repair of the orbits in a patient who autoenucleated both eyes. Main Outcome Measures: To determine methods to prevent self-destructive behavior. Results: Up to 75% of these acts are performed by psychiatric inpatients as a form of focal suicide. Methods to prevent self-inflicting behavior include differential reinforcement, boxing gloves, soft cotton gloves, a bubble helmet, facial screening, electrical stimulation, and tarsorraphy. Conclusions: Prevention of autoenucleation requires early identification of susceptible subjects and timely initiation of preventive measures.

Increasing hip fracture incidence in California Hispanics, 1983 to 2000.

Hip fracture incidence in non-Hispanic whites (NHW) has decreased nationwide for the past 20 years. Little is known regarding hip fracture incidence among Hispanics, the largest, fastest growing minority in the United States. To assess the change in standardized hip fracture incidence from 1983 through 2000 in California Hispanics relative to other racial groups. Hospitalizations for individuals older than 55 years with hip fracture requiring repair in acute care hospitals. Annual population estimates based on US Census Bureau estimates. Incidence standardized to national gender-age strata. Change in annual incidence calculated by weighted linear regression with robust variance estimates. 372,078 hip fractures were identified. Age-adjusted annual incidence of hip fractures declined by 0.74% per year among women (655 to 568 per 100,000), but was unchanged among men (247 to 238 per 100,000). Among NHW women, the standardized annual incidence fell by 0.6% (4.0 fractures per 100,000) per year. Annual incidence among Hispanic women increased 4.9% (11.1 fractures per 100,000) per year. Annual incidence among Hispanic men increased by 4.2% (4.5 fractures per 100,000) per year and among NHW men by 0.5% (1.2 fractures per 100,000) per year. No significant change occurred among black or Asian women or men. Among California women, hip fracture incidence has doubled among Hispanics since 1983, while remaining unchanged or declining in other groups. Greater attention should be given to identification of individuals at risk for hip fracture and initiation of preventive measures in Hispanic populations.

AN OUTBREAK OF LEPTOSPIROSIS AMONG PERUVIAN MILITARY RECRUITS

Acute undifferentiated febrile illnesses are common in tropical developing countries but are difficult to diagnose on clinical grounds alone. Leptospirosis is rarely diagnosed, despite evidence that sporadic cases and epidemics continue to occur worldwide. The purpose of this study was to diagnose an outbreak of acute undifferentiated febrile illness among Peruvian military recruits that developed after a training exercise in the high jungle rainforest of Peru. Of 193 military recruits, 78 developed an acute febrile illness with varied manifestations. Of these, 72 were found to have acute leptospirosis by a microscopic agglutination test (MAT). An enzyme-linked immunosorbent assay using Leptospira biflexa antigen was insensitive for the detection of anti-leptospiral IgM antibodies compared with the MAT (20 of 72, 28%). This outbreak of acute undifferentiated febrile illness among Peruvian military recruits was due to leptospirosis. High clinical suspicion, initiation of preventative measures, and performance of appropriate diagnostic testing is warranted in similar settings to identify, treat, and prevent leptospirosis.

Juvenile Sentencing: The New York Youth Part as a Model

Journal. FSR gratefully acknowledges the Journal's permission to print this article. Virtually all children sentenced as Offenders in the adult court, with the exception of those convicted of murder, will return to society by the age of 21. This fact alone highlights the importance of an effective juvenile sentencing policy. When sentencing juveniles under 16 years of age pursuant to New York's Juvenile Offender Law, judges have a special obligation to pro tect society through the initiation of preventative mea sures leading to the rehabilitation of the child. In his concurring opinion in Smith v. Daily Mail Publishing Company,1 then Justice William Rehnquist stated: [A] court concerned with juvenile affairs serves as a and protective agency of the State. All judicial sentences are based on cultural and individual assumptions about the nature of life and the values of our society. Even though retribution has gained favor as the dominant sentencing rationale for adults in recent years, and accountability is a familiar refrain for youthful miscreants, the pragmatic realization that chil dren convicted of serious crimes will return to society as still relatively young men and women, lends critical sup port to the goal of rehabilitation as the underlying ratio nale for juvenile sentences.2 There are many critics of the rehabilitative ideal, however, who argue that it is an unattainable illusion, given the present state of our knowledge about criminal behavior. I do not agree that rehabilitation is unattainable.