Impact of Torture on Refugees Displaced Within the Developing World: Symptomatology Among Bhutanese Refugees in Nepal

Context.— Most of the world's refugees are displaced within the developing world. The impact of torture on such refugees is unknown. Objective.— To examine the impact of torture on Bhutanese refugees in Nepal. Design.— Case-control survey. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD), anxiety, and depression. Setting.— Bhutanese refugee community in the United Nations refugee camps in the Terai in eastern Nepal. Participants.— A random sample of 526 tortured refugees and a control group of 526 nontortured refugees matched for age and sex. Main Outcome Measures.— The Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and anxiety. Results.— The 2 groups were similar on most demographic variables. The tortured refugees, as a group, suffered more on 15 of 17 DSM-III-R PTSD symptoms (P<.005) and had higher HSCL-25 anxiety and depression scores (P<.001) than nontortured refugees. Logistic regression analysis showed that history of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7; 95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety (OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal system– and respiratory system–related complaints (P<.001 for both). Conclusion.— Torture plays a significant role in the development of PTSD, depression, and anxiety symptoms among refugees from Bhutan living in the developing world.      

Prevalence of Articles With Honorary Authors and Ghost Authors in Peer-Reviewed Medical Journals

Context.— Authorship in biomedical publications establishes accountability, responsibility, and credit. Misappropriation of authorship undermines the integrity of the authorship system, but accurate data on its prevalence are limited. Objectives.— To determine the prevalence of articles with honorary authors (named authors who have not met authorship criteria) and ghost authors (individuals not named as authors but who contributed substantially to the work) in peer-reviewed medical journals and to identify journal characteristics and article types associated with such authorship misappropriation. Design.— Mailed, self-administered, confidential survey. Participants.— A total of 809 corresponding authors (1179 surveyed, 69% response rate) of articles published in 1996 in 3 peer-reviewed, large-circulation general medical journals (Annals of Internal Medicine, JAMA, and The New England Journal of Medicine) and 3 peer-reviewed, smaller-circulation journals that publish supplements (American Journal of Cardiology, American Journal of Medicine, and American Journal of Obstetrics and Gynecology). Main Outcome Measures.— Prevalence of articles with honorary authors and ghost authors, as reported by corresponding authors. Results.— Of the 809 articles, 492 were original research reports, 240 were reviews and articles not reporting original data, and 77 were editorials. A total of 156 articles (19%) had evidence of honorary authors (range, 11%-25% among journals); 93 articles (11%) had evidence of ghost authors (range, 7%-16% among journals); and 13 articles (2%) had evidence of both. The prevalence of articles with honorary authors was greater among review articles than research articles (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.6) but did not differ significantly between large-circulation and smaller-circulation journals (OR, 1.4; 95% CI, 0.96-2.03). Compared with similar-type articles in large-circulation journals, articles with ghost authors in smaller-circulation journals were more likely to be reviews (OR, 4.2; 95% CI, 1.5-13.5) and less likely to be research articles (OR, 0.49; 95% CI, 0.27-0.88). Conclusion.— A substantial proportion of articles in peer-reviewed medical journals demonstrate evidence of honorary authors or ghost authors.      

Violence and Threats of Violence Experienced by Public Health Field-Workers

Context.— Public health workers may work with clients whose behaviors are risks for both infectious disease and violence. Objective.— To assess frequency of violent threats and incidents experienced by public health workers and risk factors associated with incidents. Design.— Anonymous, self-administered questionnaires. Setting.— Texas sexually transmitted disease (STD), human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS), and tuberculosis (TB) programs. Participants.— Questionnaires were completed by 364 (95.5%) of 381 public health workers assigned to the programs. The STD program employed 131 workers (36%), the HIV/AIDS program, 121 workers (33%), and the TB program, 112 workers (31%). Main Outcome Measures.— The frequencies with which workers had ever experienced (while on the job) verbal threats, weapon threats, physical attacks, and rape, and risk factors associated with those outcomes. Results.— A total of 139 (38%) of 364 workers reported 611 violent incidents. Verbal threats were reported by 136 workers (37%), weapon threats by 45 (12%), physical attacks by 14 (4%), and rape by 3 (1%). Five workers (1%) carried guns and/or knives while working. In multiple logistic regression, receipt of verbal threats was associated with worker's male sex (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.5-4.0), white ethnicity (OR, 2.4; 95% CI, 1.4-4.1), experience of 5 years or longer (OR, 2.2; 95% CI, 1.3-3.8), weekend work (OR, 1.8; 95% CI, 1.1-3.1), and sexual remarks made to the worker by clients (OR, 2.0; 95% CI, 1.2-3.5). Receipt of weapon threats was associated with worker's male sex (OR, 5.7; 95% CI, 2.4-15.3), white ethnicity (OR, 4.0; 95% CI, 1.8-9.3), age of 40 years or older (OR, 2.5; 95% CI, 1.1-5.8), work experience of 5 years or longer (OR, 2.7; 95% CI, 1.2-6.0), rural work (OR, 3.6; 95% CI, 1.3-10.1), being alone with the opposite sex (OR, 3.7; 95% CI, 1.6-9.7), and interaction with homeless clients (OR, 5.2; 95% CI, 1.7-18.8). Physical attacks were associated with sexual remarks made to the worker by clients (OR, 4.2; 95% CI, 1.4-13.9). No risk factors predicting rape were identified. Conclusions.— Violence directed toward public field-workers is a common occupational hazard. An assessment of what situations, clients, and locations pose the risk of violence to public health workers is needed.      

Acute renal failure in critically ill patients: a multinational, multicenter study

Context  Although acute renal failure (ARF) is believed to be common in the setting of critical illness and is associated with a high risk of death, little is known about its epidemiology and outcome or how these vary in different regions of the world. Objectives  To determine the period prevalence of ARF in intensive care unit (ICU) patients in multiple countries; to characterize differences in etiology, illness severity, and clinical practice; and to determine the impact of these differences on patient outcomes. Design, Setting, and Patients  Prospective observational study of ICU patients who either were treated with renal replacement therapy (RRT) or fulfilled at least 1 of the predefined criteria for ARF from September 2000 to December 2001 at 54 hospitals in 23 countries. Main Outcome Measures  Occurrence of ARF, factors contributing to etiology, illness severity, treatment, need for renal support after hospital discharge, and hospital mortality. Results  Of 29 269 critically ill patients admitted during the study period, 1738 (5.7%; 95% confidence interval [CI], 5.5%-6.0%) had ARF during their ICU stay, including 1260 who were treated with RRT. The most common contributing factor to ARF was septic shock (47.5%; 95% CI, 45.2%-49.5%). Approximately 30% of patients had preadmission renal dysfunction. Overall hospital mortality was 60.3% (95% CI, 58.0%-62.6%). Dialysis dependence at hospital discharge was 13.8% (95% CI, 11.2%-16.3%) for survivors. Independent risk factors for hospital mortality included use of vasopressors (odds ratio [OR], 1.95; 95% CI, 1.50-2.55; P<.001), mechanical ventilation (OR, 2.11; 95% CI, 1.58-2.82; P<.001), septic shock (OR, 1.36; 95% CI, 1.03-1.79; P = .03), cardiogenic shock (OR, 1.41; 95% CI, 1.05-1.90; P = .02), and hepatorenal syndrome (OR, 1.87; 95% CI, 1.07-3.28; P = .03). Conclusion  In this multinational study, the period prevalence of ARF requiring RRT in the ICU was between 5% and 6% and was associated with a high hospital mortality rate.      

Physicians Disciplined by a State Medical Board

Context.— State medical boards discipline several thousand physicians each year. Although certain subgroups, such as those disciplined for malpractice, substance use, or sexual abuse, have been studied, little is known about disciplined physicians as a group. Objective.— To assess the offenses, contributing factors, and type of discipline of a consecutive series of disciplined physicians. Design.— Case-control study on publicly available data matching 375 disciplined physicians with 2 groups of control physicians, one matched solely by locale, and a second matched for sex, type of practice, and locale. Subjects.— All disciplined physicians publicly reported by the Medical Board of California from October 1995 through April 1997. Main Outcome Measures.— Characteristics of disciplined physicians, offenses leading to discipline, and type of discipline. Results.— A total of 375 physicians licensed by the Medical Board of California (approximately 0.24% per year) were disciplined for 465 offenses. The most frequent causes for discipline were negligence or incompetence (34%), abuse of alcohol or other drugs (14%), inappropriate prescribing practices (11%), inappropriate contact with patients (10%), and fraud (9%). Discipline imposed was revocation of medical license (21%), actual suspension of license (13%), stayed suspension of license (45%), and reprimand (21%). Type of offense was significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians with controls matched by locale, board discipline was significantly associated with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval [CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI, 1.75-3.75). In the regression model with additional matching criteria, disciplinary action was negatively associated with specialty board certification (OR, 0.42; 95% CI, 0.29-0.60) and positively associated with being in practice more than 20 years (OR, 2.02; 95% CI, 1.39-2.92). Conclusions.— A small but substantial proportion of physicians is disciplined each year for a variety of offenses. Further study of disciplined physicians is necessary to identify physicians at high risk for offenses leading to disciplinary action and to develop effective interventions to prevent these offenses.      

Self-reported Antiretroviral Therapy in Injection Drug Users

Context.— The US Public Health Service and the International AIDS Society–USA recently published recommendations for antiretroviral therapy (ART) for persons infected with human immunodeficiency virus (HIV); however, anecdotal evidence suggests that HIV-infected injection drug users (IDUs) may not be receiving optimal care as defined by the recommendations. Objective.— To assess ART use in HIV-infected IDUs. Design.— A cross-sectional survey of self-reported ART use between July 1996 and June 1997 in IDUs. Setting.— A community-based clinic affiliated with Johns Hopkins University, Baltimore, Md. Participants.— A total of 404 HIV-infected IDUs with CD4⁺ cell counts less than 0.50x10⁹/L recruited into a longitudinal study in 1988 and 1989. Main Outcome Measure.— Self-reported ART use was assessed: no current therapy, monotherapy, or combination therapy with or without a protease inhibitor. Results.— One half (199/404 [49%]) of patients reported no recent ART. A total of 14% (58/404) had monotherapy, 23% (90/404) were receiving combination therapy without a protease inhibitor, and 14% (57/404) had triple-combination therapy with a protease inhibitor. A multivariate analysis of factors associated with ART showed that care continuity and recent HIV-related outpatient visit (odds ratio [OR], 4.30; 95% confidence interval [CI], 2.36-7.81 and OR, 2.84; 95% CI, 1.66-4.88, respectively), CD4⁺ cell count of less than 0.20x10⁹ (OR, 2.41; 95% CI, 1.51-3.84), no current drug use and being in drug treatment (OR, 2.16; 95% CI, 1.34-3.47; OR, 2.12; 95% CI, 1.23-3.66, respectively), and unemployment (OR, 2.31; 95% CI, 1.21-4.40) were associated with reporting ART use. In other analysis, less likely to receive protease inhibitors were current drug injectors (OR, 0.5; 95% CI, 0.3-1.0) and those recently incarcerated (OR, 0.2; 95% CI, 0.03-0.9), but patients with acquired immunodeficiency syndrome were more likely to receive protease inhibitors (OR, 2.0; 95% CI, 0.9-4.6). Protease inhibitor use doubled (P<.01) from July and December 1996 to January and June 1997 (7.7% and 14.8%, respectively). Conclusions.— Those IDUs infected with HIV who were not receiving ART tended to be active drug users without clinical disease who have less contact with health care providers. Although we do not have information on clinical judgment regarding treatment decisions or whether persons were prescribed therapy not taken, the proportion of subjects reporting receiving ART suggests that strategies for improving treatment in this population are indicated. Expanding simultaneous treatment services for HIV infection and substance abuse would enhance the response to these related epidemics.      

Risk of Fatal Pulmonary Embolism in Patients With Treated Venous Thromboembolism

Context.— The most serious complication of deep vein thrombosis (DVT) or nonfatal pulmonary embolism (PE) is fatal PE. However, reliable estimates as to the risk of fatal PE in patients with treated DVT or PE are lacking. Objective.— To provide reliable estimates of the risk of fatal PE and the case-fatality rate of recurrent DVT or PE among patients presenting with symptomatic DVT or PE, during and following 3 months of anticoagulant therapy. Data Sources.— A MEDLINE literature search was performed to identify prospective studies in which patients with symptomatic DVT or PE were treated with 5 to 10 days of heparin and 3 months of oral anticoagulants. We searched the years 1966 to September 1997 using the search terms thrombophlebitis, diagnosis, drug therapy, and prognosis. Current Contents and bibliographies were also scanned. Data Extraction.— Of 137 retrieved studies, 25 studies satisfied predetermined methodologic criteria and were included in the analysis. Data Synthesis.— Among patients presenting with DVT, the rate of fatal PE during anticoagulant therapy was 0.4% (95% confidence interval [CI], 0.2%-0.6%); following anticoagulant therapy it was 0.3 per 100 patient-years (95% CI, 0.1-0.8). The case-fatality rate of recurrent DVT or PE during anticoagulant therapy was 8.8% (95% CI, 5.0%-14.1%); following anticoagulant therapy it was 5.1% (95% CI, 1.4%-12.5%). Among patients presenting with PE, the rate of fatal PE during anticoagulant therapy was 1.5% (95% CI, 0.9%-2.2%); following anticoagulant therapy it was 0 per 265 patient-years (95% CI, 0-3.6). The case-fatality rate of recurrent DVT or PE among patients presenting with PE was 26.4% (95% CI, 16.7%-38.1%). Conclusion.— Among patients with symptomatic PE or DVT who are treated with anticoagulants for 3 months, fatal PE is rare during and following anticoagulant therapy. Patients presenting with PE are more likely to die of recurrent PE or DVT than are patients presenting with DVT.      

Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities

Context  Little is known about the prevalence and characteristics of chronic pain among patients with different types of chemical dependency. Objectives  To estimate the prevalence and to examine the characteristics of chronic severe pain in chemically dependent populations receiving methadone maintenance or inpatient residential treatment. Design, Setting, and Participants  Representative samples of 390 patients from 2 methadone maintenance treatment programs (MMTPs) and 531 patients from 13 short-term residential substance abuse treatment (inpatient) programs, all in New York State, were surveyed in late 2000 and early 2001. Main Outcome Measure  Prevalence of chronic severe pain, defined as pain that persisted for more than 6 months and was of moderate to severe intensity or that significantly interfered with daily activities. Results  Chronic severe pain was experienced by 37% of MMTP patients (95% confidence interval [CI], 32%-41%) and 24% of inpatients (95% CI, 20%-28%; P = .03). Pain of any type or duration during the past week was reported by 80% of MMTP patients and 78% of inpatients. Among those with chronic severe pain, 65% of MMTP patients and 48% of inpatients reported high levels of pain-related interference in physical and psychosocial functioning. Among MMTP patients, correlates of chronic pain in a multivariate model were age (odds ratio [OR], 2.08; 95% CI, 1.17-3.70), chronic illness (OR, 1.88; 95% CI, 1.07-3.29), lifetime psychiatric illness (OR, 1.77; 95% CI, 1.06-2.97), psychiatric distress (OR, 1.63; 95% CI, 1.22-2.18), and time in treatment (OR, 2.23; 95% CI, 1.06-4.68). Among inpatients, the correlates of chronic pain were race (blacks vs whites: OR, 0.52; 95% CI, 0.31-0.90; Hispanics vs whites: OR, 0.48; 95% CI, 0.24-0.95), drug craving (OR, 2.78; 95% CI, 1.54-5.02), chronic illness (OR, 2.17; 95% CI, 1.37-3.43), and psychiatric distress (OR, 1.36; 95% CI, 1.03-1.81). Among those with chronic severe pain, inpatients were significantly more likely than MMTP patients to have used illicit drugs, as well as alcohol, to treat their pain complaint (51% vs 34%, P = .005) but were less likely to have been prescribed pain medications (52% vs 67%, P = .01). Conclusions  Chronic severe pain is prevalent among patients in substance abuse treatment, especially MMTP patients. Pain is associated with functional impairment and correlates of pain vary with the population. Self-medication for pain with psychoactive drugs appears especially problematic among substance users who enroll in drug-free treatment programs. Substance abuse treatment programs need to develop comprehensive and structured pain management programs.      

Hunger in an Adult Patient Population

Context.— Although clinical observations suggest that some patients experience hunger and food insecurity, there are limited data on the prevalence of hunger in adult patients. Objective.— To determine the prevalence of hunger and food insecurity in adult patients at an urban county hospital. Design.— Cross-sectional survey conducted in 1997. Patients.— The primary survey included all patients aged 18 years or older who were admitted to the medicine, surgery, and neurology services during a 2-week period, and all patients who attended the hospital's general medicine clinic during 1 week. A second survey included primary care patients who received insulin from the hospital pharmacy during a 1-month period. Main Outcome Measures.— Rates of hunger and food insecurity. Results.— Of 709 eligible patients, 567 (participation rate, 80%) were interviewed in either the clinic (n=281) or hospital (n=286). An additional 170 patients who received insulin were interviewed by telephone (response rate, 75%). Of the primary sample, 68 (12%) respondents reported not having enough food, 75 (13%) reported not eating for an entire day, and 77 (14%) reported going hungry but not eating because they could not afford food. A total of 222 (40%) had received food stamps in the previous year and of those, 113 (50%) had their food stamps reduced or eliminated. Recipients whose food stamps had been eliminated or reduced were more likely to report not having enough food (18% vs 13%,P=.006), not eating for a whole day (20% vs 16%, P=.01), going hungry but not eating (20% vs 16%, P=.08), and cutting down on the size of meals or skipping meals (33% vs 27%,P=.01). In multivariate analysis, independent predictors of hunger included an annual income of less than $10000 (odds ratio [OR], 7.55; 95% CI, 3.01-18.92), drug use (OR, 3.56; 95% CI, 1.46-8.66), and a reduction in food stamp benefits (OR, 1.73; 95% CI, 1.01-2.96). Predictors of food insecurity included an annual income of less than $10000 (OR, 4.12; 95% confidence interval [CI], 1.98-8.58), drug use (OR, 2.11; 95% CI, 1.66-5.08), and a reduction in food stamps (OR, 2.02; 95% CI, 1.23-3.32). In addition, 103 (61%) patients in the sample of diabetics reported hypoglycemic reactions; 32 (31%) of these were attributed to inability to afford food. Conclusion.— Hunger and food insecurity are common among patients seeking care at an urban county hospital.      

Medicine residents' understanding of the biostatistics and results in the medical literature

Context  Physicians depend on the medical literature to keep current with clinical information. Little is known about residents' ability to understand statistical methods or how to appropriately interpret research outcomes. Objective  To evaluate residents' understanding of biostatistics and interpretation of research results. Design, Setting, and Participants  Multiprogram cross-sectional survey of internal medicine residents. Main Outcome Measure  Percentage of questions correct on a biostatistics/study design multiple-choice knowledge test. Results  The survey was completed by 277 of 367 residents (75.5%) in 11 residency programs. The overall mean percentage correct on statistical knowledge and interpretation of results was 41.4% (95% confidence interval [CI], 39.7%-43.3%) vs 71.5% (95% CI, 57.5%-85.5%) for fellows and general medicine faculty with research training (P < .001). Higher scores in residents were associated with additional advanced degrees (50.0% [95% CI, 44.5%-55.5%] vs 40.1% [95% CI, 38.3%-42.0%]; P < .001); prior biostatistics training (45.2% [95% CI, 42.7%-47.8%] vs 37.9% [95% CI, 35.4%-40.3%]; P = .001); enrollment in a university-based training program (43.0% [95% CI, 41.0%-45.1%] vs 36.3% [95% CI, 32.6%-40.0%]; P = .002); and male sex (44.0% [95% CI, 41.4%-46.7%] vs 38.8% [95% CI, 36.4%-41.1%]; P = .004). On individual knowledge questions, 81.6% correctly interpreted a relative risk. Residents were less likely to know how to interpret an adjusted odds ratio from a multivariate regression analysis (37.4%) or the results of a Kaplan-Meier analysis (10.5%). Seventy-five percent indicated they did not understand all of the statistics they encountered in journal articles, but 95% felt it was important to understand these concepts to be an intelligent reader of the literature. Conclusions  Most residents in this study lacked the knowledge in biostatistics needed to interpret many of the results in published clinical research. Residency programs should include more effective biostatistics training in their curricula to successfully prepare residents for this important lifelong learning skill.      

Short-term prognosis after emergency department diagnosis of TIA

Context  Management of patients with acute transient ischemic attack (TIA) varies widely, with some institutions admitting all patients and others proceeding with outpatient evaluations. Defining the short-term prognosis and risk factors for stroke after TIA may provide guidance in determining which patients need rapid evaluation. Objective  To determine the short-term risk of stroke and other adverse events after emergency department (ED) diagnosis of TIA. Design and Setting  Cohort study conducted from March 1997 through February 1998 in 16 hospitals in a health maintenance organization in northern California. Patients  A total of 1707 patients (mean age, 72 years) identified by ED physicians as having presented with TIA. Main Outcome Measures  Risk of stroke during the 90 days after index TIA; other events, including death, recurrent TIA, and hospitalization for cardiovascular events. Results  During the 90 days after index TIA, 180 patients (10.5%) returned to the ED with a stroke, 91 of which occurred in the first 2 days. Five factors were independently associated with stroke: age greater than 60 years (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.7; P = .01), diabetes mellitus (OR, 2.0; 95% CI, 1.4-2.9; P<.001), symptom duration longer than 10 minutes (OR, 2.3; 95% CI, 1.3-4.2; P = .005), weakness (OR, 1.9; 95% CI, 1.4-2.6; P<.001), and speech impairment (OR, 1.5; 95% CI, 1.1-2.1; P = .01). Stroke or other adverse events occurred in 428 patients (25.1%) in the 90 days after the TIA and included 44 hospitalizations for cardiovascular events (2.6%), 45 deaths (2.6%), and 216 recurrent TIAs (12.7%). Conclusions  Our results indicate that the short-term risk of stroke and other adverse events among patients who present to an ED with a TIA is substantial. Characteristics of the patient and the TIA may be useful for identifying patients who may benefit from expeditious evaluation and treatment.      

Influence of a Child's Sex on Medulloblastoma Outcome

Context.— Aggressive treatment of medulloblastoma, the most common pediatric brain tumor, has not improved survival. Identifying better prognostic indicators may warrant less morbid therapy. Objective.— To investigate the role of sex on outcome of medulloblastoma. Design.— Retrospective study of significant factors for survival with a median follow-up of 82 months. Setting.— University medical center. Patients.— A total of 109 consecutive, pediatric patients treated for primary medulloblastoma from 1970 to 1995 with surgery and postoperative radiotherapy and, after 1979, chemotherapy. Main Outcome Measures.— Factors independently associated with survival. Results.— The final multivariate model predicting improved survival included sex (hazard ratio, 0.52; 95% confidence interval [CI], 0.29-0.92; P=.03; favoring female), metastases at presentation (hazard ratio, 2.01; 95% CI, 1.14-3.52; P=.02), and extent of surgical resection (hazard ratio, 0.60; 95% CI, 0.34-1.04; P=.07; favoring greater resection). The overall, 5-year freedom from progression was 40% and survival was 49%. Radiotherapy dose (P=.72), and chemotherapy (P=.90) did not significantly affect a disease outcome. Conclusions.— The sex of the child was an important predictor for survival of medulloblastoma; girls had a much better outcome. The difference in survival between sexes should be evaluated in prospective, clinical trials.      

Circulating androgen levels and self-reported sexual function in women

Context  It has been proposed that low sexual desire and sexual dysfunction are associated with low blood testosterone levels in women. However, evidence to support this is lacking. Objective  To determine whether women with low self-reported sexual desire and sexual satisfaction are more likely to have low serum androgen levels than women without self-reported low sexual desire and sexual satisfaction. Design, Setting, and Participants  A community-based, cross-sectional study of 1423 women aged 18 to 75 years, who were randomly recruited via the electoral roll in Victoria, Australia, from April 2002 to August 2003. Women were excluded from the analysis if they took psychiatric medication, had abnormal thyroid function, documented polycystic ovarian syndrome, or were younger than 45 years and using oral contraception. Main Outcome Measures  Domain scores of the Profile of Female Sexual Function (PFSF) and serum levels of total and free testosterone, androstenedione, and dehydroepiandrosterone sulfate. Results  A total of 1021 individuals were included in the final analysis. No clinically significant relationships between having a low score for any PFSF domain and having a low serum total or free testosterone or androstenedione level was demonstrated. A low domain score for sexual responsiveness for women aged 45 years or older was associated with higher odds of having a serum dehydroepiandrosterone sulfate level below the 10th percentile for this age group (odds ratio [OR], 3.90; 95% confidence interval [CI], 1.54-9.81; P = .004). For women aged 18 to 44 years, having a low domain score for sexual desire (OR, 3.86; 95% CI, 1.27-11.67; P = .02), sexual arousal (OR, 6.39; 95% CI, 2.30-17.73; P<.001), and sexual responsiveness (OR, 6.59; 95% CI, 2.37-18.34; P<.001) was associated with having a dehydroepiandrosterone sulfate level below the 10th percentile. Conclusions  No single androgen level is predictive of low female sexual function, and the majority of women with low dehydroepiandrosterone sulfate levels did not have low sexual function.      

Sexual Abuse of Boys: Definition, Prevalence, Correlates, Sequelae, and Management

Objective.— To clarify the definition of sexual abuse of boys, update estimates of its prevalence, and explore critically its reported correlates, sequelae, and management. Data Sources.— Studies from 1985 to 1997 were identified using OVID-MEDLINE and OVID-CINAHL. The search terms used were sexual abuse, sexual victimization, and sexual assault. Constraints applied included English language, human male subjects, age younger than 19 years, and North American samples. Study Selection.— Publications were included for review if they appeared in peer-reviewed journals; had clear research designs; reported results for at least 20 male subjects; and were not reviews, perspectives, theoretical treatises, editorials, or letters. Data Extraction.— Study types and sampling methods were categorized using well-established definitions. Preference was given to studies with large samples, with case-control or cohort designs, and/or with adjustment for effect modifiers or confounders. Data Synthesis.— We identified 166 studies representing 149 sexual abuse samples. Studies were methodologically limited and definitions of sexual abuse varied widely. Prevalence estimates varied widely (by definition used and population studied), ranging from 4% to 76%. Boys at highest risk were younger than 13 years, nonwhite, of low socioeconomic status, and not living with their fathers. Perpetrators tended to be known but unrelated males. Abuse frequently occurred outside the home, involved penetration, and occurred more than once. Sequelae included psychological distress, substance abuse, and sexually related problems. Evaluation of management strategies was limited. Conclusions.— Sexual abuse of boys appears to be common, underreported, underrecognized, and undertreated. Future study requires clearer definitions of abuse, improved sampling, more rigorous data collection, more sophisticated data analyses, and better assessment of management and treatment strategies. Regardless, health care professionals should be more aware of and sensitive to the possibility of sexual abuse in their male patients.      

Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents: A Randomized Controlled Trial

Context.— African American adolescents are at high risk of contracting sexually transmitted infection with human immunodeficiency virus (HIV), but which behavioral interventions to reduce risk are most effective and who should conduct them is not known. Objective.— To evaluate the effects of abstinence and safer-sex HIV risk-reduction interventions on young inner-city African American adolescents' HIV sexual risk behaviors when implemented by adult facilitators as compared with peer cofacilitators. Design.— Randomized controlled trial with 3-, 6-, and 12-month follow-up. Setting.— Three middle schools serving low-income African American communities in Philadelphia, Pa. Participants.— A total of 659 African American adolescents recruited for a Saturday program. Interventions.— Based on cognitive-behavioral theories and elicitation research, interventions involved 8 1-hour modules implemented by adult facilitators or peer cofacilitators. Abstinence intervention stressed delaying sexual intercourse or reducing its frequency; safer-sex intervention stressed condom use; control intervention concerned health issues unrelated to sexual behavior. Main Outcome Measures.— Self-reported sexual intercourse, condom use, and unprotected sexual intercourse. Results.— Mean age of the enrollees was 11.8 years; 53% were female and 92.6% were still enrolled at 12 months. Abstinence intervention participants were less likely to report having sexual intercourse in the 3 months after intervention than were control group participants (12.5% vs 21.5%, P=.02), but not at 6- or 12-month follow-up (17.2% vs 22.7%, P=.14; 20.0% vs 23.1%, P=.42, respectively). Safer-sex intervention participants reported significantly more consistent condom use than did control group participants at 3 months (odds ratio [OR]=3.38; 95% confidence interval [CI], 1.25-9.16) and higher frequency of condom use at all follow-ups. Among adolescents who reported sexual experience at baseline, the safer-sex intervention group reported less sexual intercourse in the previous 3 months at 6- and 12-month follow-up than did control and abstinence intervention (adjusted mean days over prior 3 months, 1.34 vs 3.77 and 3.03, respectively; P.01 at 12-month follow-up) and less unprotected intercourse at all follow-ups than did control group (adjusted mean days, 0.04 vs 1.85, respectively, P<.001, at 12-month follow-up). There were no differences in intervention effects with adult facilitators as compared with peer cofacilitators. Conclusion.— Both abstinence and safer-sex interventions can reduce HIV sexual risk behaviors, but safer-sex interventions may be especially effective with sexually experienced adolescents and may have longer-lasting effects.      

Low Dosage and Long Treatment Duration of {beta}-Lactam: Risk Factors for Carriage of Penicillin-Resistant Streptococcus pneumoniae

Context.— The spread of drug-resistant Streptococcus pneumoniae in the community is a public health problem in developed and developing nations, but whether antibiotic use is responsible for the increase in drug resistance is not known. Objective.— To analyze the relationship between penicillin-resistant S pneumoniae (PR Sp) pharyngeal carriage and characteristics of -lactam use. Design.— Observational study of children attending 20 randomly sampled schools. Setting.— The Loiret, in the center of France. Participants.— A total of 941 children, 3 to 6 years old. Main Outcome Measure(s).— Pharyngeal carriage of S pneumoniae, antibiotic use, and medical events during the preceding 30 days. Pneumococcal penicillin G sodium minimal inhibitory concentrations and serotyping were performed. Results.— Medical illnesses and the use of antibiotics were not associated with PR Sp carriage. However, oral -lactam use was associated with an increased risk of PR Sp carriage (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1-8.3; P=.03). Children treated by low daily doses of an oral -lactam (defined as lower than clinical recommendations) had an increased risk of PR Sp carriage, as compared with children who did not (OR, 5.9; 95% CI, 2.1-16.7; P =.002). A treatment of long duration (>5 days) with a -lactam was associated with an increased risk of PR Sp carriage (OR, 3.5; 95% CI, 1.3-9.8; P=.02). Conclusions.— Our results suggest that a low daily dose and a long duration of treatment with an oral -lactam contribute to the selective pressure in promoting pharyngeal carriage of PR Sp.      

Possible Effectiveness of Clarithromycin and Rifabutin for Cryptosporidiosis Chemoprophylaxis in HIV Disease

Context.— Cryptosporidium parvum infection, a common cause of diarrhea in persons infected with the human immunodeficiency virus (HIV), is difficult to treat or prevent. Objective.— To evaluate relative rates of cryptosporidiosis in HIV-infected patients who were either receiving or not receiving chemoprophylaxis or treatment for Mycobacterium avium complex. Design.— Analysis of prospectively collected data from HIV-infected patients' visits to their physicians since 1992. Setting.— Ten (8 private, 2 publicly funded) HIV clinics in 9 US cities. Patients.— A total of 1019 HIV-infected patients with CD4⁺ cell counts less than 0.075x10⁹/L. Main Outcome Measures.— Incidence of clinical cryptosporidiosis during treatment with clarithromycin, rifabutin, and azithromycin. Results.— Five of the 312 patients reportedly taking clarithromycin developed cryptosporidiosis vs 30 of the 707 patients not taking clarithromycin (relative hazard [RH], 0.25 [95% confidence interval (CI), 0.10-0.67]; P =.004).Two of the 214 patients taking rifabutin developed cryptosporidiosis vs 33 of the 805 not taking rifabutin (RH, 0.15 [95% CI, 0.04-0.62]; P=.01). Prophylactic efficacy of either drug was 75% or greater. No protective effect was seen in the 54 patients reportedly taking azithromycin (RH, 1.48 [95% CI, 0.44-5.04]; P=.46). Conclusions.— Clarithromycin and rifabutin were highly protective against development of cryptosporidiosis in immune-suppressed HIV-infected persons in this analysis; further study is warranted.      

Changes in Sleep Position During Infancy: A Prospective Longitudinal Assessment

Context.— Prone sleeping by infants has been associated with an increased risk of sudden infant death syndrome. Objective.— To document the prevalence of and identify risk factors for prone sleeping during the first 6 months of life. Design.— Prospective cohort study. Setting.— Eastern Massachusetts and northwest Ohio. Study Participants.— A total of 7796 mothers of infants weighing 2500 g or more at birth. Main Outcome Measures.— Maternal and infant characteristics related to prone sleeping at 1 month and 3 months of age. Results.— Between 1 month and 3 months of age, prone sleeping increased from 18% to 29%. At 1 month, prone sleeping was associated with the following maternal characteristics: non-Hispanic black or Hispanic race/ethnicity, younger age, less education, and higher parity. At 3 months, switching from nonprone to prone position was associated with mother's race/ethnicity of non-Hispanic black (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.3) or Hispanic (OR, 1.5; 95% CI, 1.1-2.2); younger maternal age (compared with mothers >34 years: 18-24 years, OR, 1.6; 95% CI, 1.2-2.2; <18 years, OR, 2.2; 95% CI, 1.2-4.3); increasing parity (compared with 1 child: 2 children, OR, 1.5; 95% CI, 1.2-1.8; 3 children, OR, 1.7; 95% CI, 1.4-2.2); and infant sex (male sex, OR, 1.4; 95% CI, 1.2-1.7). Conclusions.— If infant sleeping practices in the study communities are representative of practices throughout the United States, a substantial number of infants who slept nonprone at 1 month sleep prone at 3 months.      

Incidence of Dog Bite Injuries Treated in Emergency Departments

Context.— Dog bites that result in injuries occur frequently, but how frequently dog bite injuries necessitate medical attention at a hospital or hospital admission is unknown. Objective.— To describe the incidence and characteristics of dog bite injuries treated in US emergency departments (EDs). Design.— Emergency department survey from the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1992 to 1994. Patients.— National probability sample of patients visiting EDs. Main Outcome Measure.— Incidence of dog bites treated in EDs, defined as a cause of injury recorded as the E-code E906.0. Results.— The 3-year annualized, adjusted, and weighted estimate of new dog bite–related injury visits to US EDs was 333687, a rate of 12.9 per 10000 persons (95% confidence interval [CI], 10.5-15.4). This represents approximately 914 new dog bite injuries requiring ED visits per day. The median age of patients bitten was 15 years, with children, especially boys aged 5 to 9 years, having the highest incidence rate (60.7 per 10000 persons for boys aged 5 to 9 years). Children seen in EDs were more likely than older persons to be bitten on the face, neck, and head (73% vs 30%). We estimated that for each US dog bite fatality there are about 670 hospitalizations and 16000 ED visits. Conclusions.— Dog bite injuries are an important source of injury in the US population, especially among children. Improved surveillance and prevention of dog bite–related injuries, particularly among children, are needed.      

Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation

Context  Only 1% to 8% of adults with out-of-hospital cardiac arrest survive to hospital discharge. Objective  To compare resuscitation outcomes before and after an urban emergency medical services (EMS) system switched from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR. Design, Setting, and Patients  A phased, observational cohort evaluation with intention-to-treat analysis of 783 adults with out-of-hospital, nontraumatic cardiac arrest. A total of 499 patients were included in the manual CPR phase (January 1, 2001, to March 31, 2003) and 284 patients in the LDB-CPR phase (December 20, 2003, to March 31, 2005); of these patients, the LDB device was applied in 210 patients. Intervention  Urban EMS system change from manual CPR to LDB-CPR. Main Outcome Measures  Return of spontaneous circulation (ROSC), with secondary outcome measures of survival to hospital admission and hospital discharge, and neurological outcome at discharge. Results  Patients in the manual CPR and LDB-CPR phases were comparable except for a faster response time interval (mean difference, 26 seconds) and more EMS-witnessed arrests (18.7% vs 12.6%) with LDB. Rates for ROSC and survival were increased with LDB-CPR compared with manual CPR (for ROSC, 34.5%; 95% confidence interval [CI], 29.2%-40.3% vs 20.2%; 95% CI, 16.9%-24.0%; adjusted odds ratio [OR], 1.94; 95% CI, 1.38-2.72; for survival to hospital admission, 20.9%; 95% CI, 16.6%-26.1% vs 11.1%; 95% CI, 8.6%-14.2%; adjusted OR, 1.88; 95% CI, 1.23-2.86; and for survival to hospital discharge, 9.7%; 95% CI, 6.7%-13.8% vs 2.9%; 95% CI, 1.7%-4.8%; adjusted OR, 2.27; 95% CI, 1.11-4.77). In secondary analysis of the 210 patients in whom the LDB device was applied, 38 patients (18.1%) survived to hospital admission (95% CI, 13.4%-23.9%) and 12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%-9.3%). Among patients in the manual CPR and LDB-CPR groups who survived to hospital discharge, there was no significant difference between groups in Cerebral Performance Category (P = .36) or Overall Performance Category (P = .40). The number needed to treat for the adjusted outcome survival to discharge was 15 (95% CI, 9-33). Conclusion  Compared with resuscitation using manual CPR, a resuscitation strategy using LDB-CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-hospital nontraumatic cardiac arrest.