Hypertension and correlates among Montenegrin schoolchildren-a cross-sectional study.

OBJECTIVES: In one of the few national studies of children in a former Eastern bloc country emerging as a Western democracy and the first such study ever in Montenegro, this study establishes the prevalence and correlates of childhood hypertension (CH). STUDY DESIGN: A cross-sectional national study. METHODS: The study was conducted with 3254 children aged 7-13 years (50.3% male) from 39 elementary schools. We used a structured questionnaire to gather sociodemographic information as well as data on factors potentially related to CH. Children's nutritional status was assessed using the criteria of the International Obesity Task Force. Waist circumference was also measured. Blood pressure was measured in schools using an oscillometric monitor. CH was defined as an average systolic blood pressure and/or diastolic blood pressure greater than or equal to the 95th percentile for sex, age, and height. RESULTS: The prevalence of CH was 10.4% with no differences between boys and girls. Multiple regression revealed that the odds for child hypertension were lowered by 10% for each year of age. On the other hand, rural environment and child obesity raised the odds of hypertension by 38% and 68%, respectively. CONCLUSIONS: We found hypertension in one out of ten Montenegrin schoolchildren, with no gender differences. Obesity and rural areas may be unfriendly to children's blood pressure.

Common carotid intima-media thickness does not add to Framingham risk score in individuals with diabetes mellitus: the USE-IMT initiative.

AIMS/HYPOTHESIS: The aim of this work was to investigate whether measurement of the mean common carotid intima-media thickness (CIMT) improves cardiovascular risk prediction in individuals with diabetes. METHODS: We performed a subanalysis among 4,220 individuals with diabetes in a large ongoing individual participant data meta-analysis involving 56,194 subjects from 17 population-based cohorts worldwide. We first refitted the risk factors of the Framingham heart risk score on the individuals without previous cardiovascular disease (baseline model) and then expanded this model with the mean common CIMT (CIMT model). The absolute 10 year risk for developing a myocardial infarction or stroke was estimated from both models. In individuals with diabetes we compared discrimination and calibration of the two models. Reclassification of individuals with diabetes was based on allocation to another cardiovascular risk category when mean common CIMT was added. RESULTS: During a median follow-up of 8.7 years, 684 first-time cardiovascular events occurred among the population with diabetes. The C statistic was 0.67 for the Framingham model and 0.68 for the CIMT model. The absolute 10 year risk for developing a myocardial infarction or stroke was 16% in both models. There was no net reclassification improvement with the addition of mean common CIMT (1.7%; 95% CI -1.8, 3.8). There were no differences in the results between men and women. CONCLUSIONS/INTERPRETATION: There is no improvement in risk prediction in individuals with diabetes when measurement of the mean common CIMT is added to the Framingham risk score. Therefore, this measurement is not recommended for improving individual cardiovascular risk stratification in individuals with diabetes.

Manual or semi-automated edge detection of the maximal far wall common carotid intima-media thickness: a direct comparison.

BACKGROUND: Automated edge detection is thought to be superior to manual edge detection in quantification of the far wall common carotid intima-media thickness (CIMT), yet published evidence making a direct comparison is not available. METHODS: Data were used from the METEOR study, a randomized placebo-controlled trial among 984 individuals showing that rosuvastatin attenuated the rate of change of 2 year change in CIMT among low-risk individuals with subclinical atherosclerosis. For this post hoc analysis, CIMT images of the far wall of the common carotid artery were evaluated using manual and semi-automated edge detection and reproducibility, relation to cardiovascular risk factors, rates of change over time and effects of lipid-lowering therapy were assessed. RESULTS: Reproducibility was high for both reading methods. Direction, magnitude and statistical significance of risk factor relations were similar across methods. Rate of change in CIMT in participants assigned to placebo was 0.0066 mm per year (SE: 0.0027) for manually and 0.0072 mm per year (SE: 0.0029) for semi-automatically read images. The effect of lipid-lowering therapy on CIMT changes was -0.0103 mm per year (SE: 0.0032) for manual reading and -0.0111 mm per year (SE: 0.0034) for semi-automated reading. CONCLUSION: Manual and semi-automated readings of the maximal far wall of the common CIMT images both result in high reproducibility, show similar risk factor relations, rates of change and treatment effects. Hence, choices between semi-automated and manual reading software for CIMT studies likely should be based on logistical and cost considerations rather than differences in expected data quality when the choice is made to use far wall common CIMT measurements.

Use of atorvastatin in systemic lupus erythematosus in children and adolescents.

OBJECTIVE: Statins reduce atherosclerosis and cardiovascular morbidity in the general population, but their efficacy and safety in children and adolescents with systemic lupus erythematosus (SLE) are unknown. This study was undertaken to determine the 3-year efficacy and safety of atorvastatin in preventing subclinical atherosclerosis progression in pediatric-onset SLE. METHODS: A total of 221 participants with pediatric SLE (ages 10-21 years) from 21 North American sites were enrolled in the Atherosclerosis Prevention in Pediatric Lupus Erythematosus study, a randomized double-blind, placebo-controlled clinical trial, between August 2003 and November 2006 with 36-month followup. Participants were randomized to receive atorvastatin (n=113) or placebo (n=108) at 10 or 20 mg/day depending on weight, in addition to usual care. The primary end point was progression of mean-mean common carotid intima-media thickening (CIMT) measured by ultrasound. Secondary end points included other segment/wall-specific CIMT measures, lipid profile, high-sensitivity C-reactive protein (hsCRP) level, and SLE disease activity and damage outcomes. RESULTS: Progression of mean-mean common CIMT did not differ significantly between treatment groups (0.0010 mm/year for atorvastatin versus 0.0024 mm/year for placebo; P=0.24). The atorvastatin group achieved lower hsCRP (P=0.04), total cholesterol (P<0.001), and low-density lipoprotein (P<0.001) levels compared with placebo. In the placebo group, CIMT progressed significantly across all CIMT outcomes (0.0023-0.0144 mm/year; P<0.05). Serious adverse events and critical safety measures did not differ between groups. CONCLUSION: Our results indicate that routine statin use over 3 years has no significant effect on subclinical atherosclerosis progression in young SLE patients; however, further analyses may suggest subgroups that would benefit from targeted statin therapy. Atorvastatin was well tolerated without safety concerns.

Increased age, high body mass index and low HDL-C levels are related to an echolucent carotid intima-media: the METEOR study.

INTRODUCTION: Echolucent plaques are related to a higher cardiovascular risk. Studies to investigate the relationship between echolucency and cardiovascular risk in the early stages of atherosclerosis are limited. We studied the relationship between cardiovascular risk factors and echolucency of the carotid intima-media in low-risk individuals. METHODS: Data were analysed from the Measuring Effects on Intima-Media Thickness: an Evaluation of Rosuvastatin (METEOR) study, a randomized placebo-controlled trial including 984 individuals which showed that rosuvastatin attenuated the rate of change of carotid intima-media thickness (CIMT). In this post hoc analysis, duplicate baseline ultrasound images from the far wall of the left and right common carotid arteries were used for the evaluation of the echolucency of the carotid intima-media, measured by grey-scale median (GSM) on a scale of 0-256. Low GSM values reflect echolucent, whereas high values reflect echogenic structures. The relationship between baseline GSM and cardiovascular risk factors was evaluated using linear regression models. RESULTS: Mean baseline GSM (± SD) was 84 ± 29. Lower GSM of the carotid intima-media was associated with older age, high body mass index (BMI) and low levels of high-density lipoprotein cholesterol (HDL-C) [beta -4.49, 95% confidence interval (CI) -6.50 to -2.49; beta -4.51, 95% CI -6.43 to -2.60; beta 2.45, 95% CI 0.47 to 4.42, respectively]. Common CIMT was inversely related to GSM of the carotid intima-media (beta -3.94, 95% CI -1.98 to -5.89). CONCLUSION: Older age, high BMI and low levels of HDL-C are related to echolucency of the carotid intima-media. Hence, echolucency of the carotid intima-media may be used as a marker of cardiovascular risk profile to provide more information than thickness alone.

Intensive glucose control and macrovascular outcomes in type 2 diabetes.

AIMS/HYPOTHESIS: Improved glucose control in type 2 diabetes is known to reduce the risk of microvascular events. There is, however, continuing uncertainty about its impact on macrovascular disease. The aim of these analyses was to generate more precise estimates of the effects of more-intensive, compared with less-intensive, glucose control on the risk of major cardiovascular events amongst patients with type 2 diabetes. METHODS: A prospectively planned group-level meta-analysis in which characteristics of trials to be included, outcomes of interest, analyses and subgroup definitions were all pre-specified. RESULTS: A total of 27,049 participants and 2,370 major vascular events contributed to the meta-analyses. Allocation to more-intensive, compared with less-intensive, glucose control reduced the risk of major cardiovascular events by 9% (HR 0.91, 95% CI 0.84-0.99), primarily because of a 15% reduced risk of myocardial infarction (HR 0.85, 95% CI 0.76-0.94). Mortality was not decreased, with non-significant HRs of 1.04 for all-cause mortality (95% CI 0.90-1.20) and 1.10 for cardiovascular death (95% CI 0.84-1.42). Intensively treated participants had significantly more major hypoglycaemic events (HR 2.48, 95% CI 1.91-3.21). Exploratory subgroup analyses suggested the possibility of a differential effect for major cardiovascular events in participants with and without macrovascular disease (HR 1.00, 95% CI 0.89-1.13, vs HR 0.84, 95% CI 0.74-0.94, respectively; interaction p = 0.04). CONCLUSIONS/INTERPRETATION: Targeting more-intensive glucose lowering modestly reduced major macrovascular events and increased major hypoglycaemia over 4.4 years in persons with type 2 diabetes. The analyses suggest that glucose-lowering regimens should be tailored to the individual.

Intensive lipid lowering may reduce progression of carotid atherosclerosis within 12 months of treatment: the METEOR study.

BACKGROUND: In several statin trials, vascular event rates for treatment groups begin to separate 1 year after commencement of treatment. For atherosclerosis progression, the temporal sequence of the effect has not been defined. We used data from the Measuring Effects on intima media Thickness: an Evaluation Of Rosuvastatin (METEOR) trial to determine the earliest time point at which significant differences in atherosclerosis progression rates could be detected after initiation of statin therapy. METHODS: The METEOR trial was a double-blind, randomized placebo-controlled trial that studied the effect of LDL-C lowering with 40 mg rosuvastatin on the rate of change of carotid intima media thickness (CIMT) measured by B-mode ultrasound amongst 984 low risk subjects. Ultrasound assessments were made at baseline and every 6 months up to 2 years. RESULTS: Rosuvastatin treatment was associated with a 49% reduction in LDL-C-C, a 34% reduction in total cholesterol, an 8.0% increase in HDL-C and a 16% reduction in triglycerides (all P < 0.0001 compared with placebo). The difference in rate of mean maximum CIMT progression between the rosuvastatin and placebo groups (based on near and far wall measurements from both left and right common carotid and internal carotid segments and carotid bifurcation) was not statistically significant after 6 months (0.0023 mm year(-1) and 0.0106 mm year(-1), respectively P = 0.34). After 12 months, CIMT progression rates were significantly different between the groups: 0.0032 mm year(-1) and 0.0133 mm year(-1) in the rosuvastatin-treated and placebo-treated groups, respectively (P = 0.049). This divergence grew with further follow-up: -0.0009 mm year(-1) and 0.0131 mm year(-1) after 18 months (P < 0.001) and -0.0014 mm year(-1) and 0.0131 mm year(-1) after 24 months of treatment (P < 0.001). Results were stronger for the mean common CIMT progression (based on near and far wall measurements from both left and right common carotid segments). CONCLUSION: Aggressive LDL-C lowering seems to exert its beneficial effect on atherosclerosis progression during the first 12 months of treatment. This parallels the timing of event reduction seen in clinical trials and suggests that the efficacy of lipid lowering treatment on CIMT progression can be evaluated in trials with a duration of 1 year, given sufficient sample size, high precision of measurements and a treatment effect comparable to that seen in METEOR.

Ultrasound protocols to measure carotid intima-media thickness: a post-hoc analysis of the OPAL study.

OBJECTIVE: Ultrasound protocols to measure carotid intima-media thickness (CIMT) differ in the number of carotid walls, segments and angles measured. No published evidence is available to help decide which approach is best, i.e. the most reproducible and providing the largest CIMT progression rate measured with highest precision. We compared different ultrasound protocols in a post-hoc analysis in the 'Osteoporosis Prevention and Arterial effects of tiboLone' (OPAL) study, a 3-year randomized controlled trial among healthy postmenopausal women. RESEARCH DESIGN AND METHODS: Based on combinations of 60 CIMT measurements per participant (two sides, two walls, three segments, five angles), 66 theoretical protocols were constructed. Each protocol was assessed and ranked on: (1) reproducibility (intra-class correlation (ICC), mean difference of duplicate scans) and (2) CIMT progression rate and its precision (standard error) in the placebo group. RESULTS: Duplicate scans at baseline and end of study were available for 675 women (89% of 759 subjects). ICC ranged from 0.69 to 0.88. Mean difference in CIMT of duplicate scans and its standard deviation, ranged from 0.0010 to 0.0137 mm and from 0.0561 to 0.1770, respectively. CIMT rate of progression ranged from -0.0001 to 0.0113 mm/year. The protocols with highest reproducibility and highest CIMT progression-precision were mean common CIMT protocols measuring both near and far wall at > or = 2 angles. The mean maximum protocol measuring three segments at > or = 2 angles performed best, yet with lower estimates as for common CIMT protocols. CONCLUSIONS: In healthy middle-aged subjects mean common CIMT protocols that include measurements at both near and far walls at multiple (> or = 2) angles provide highest reproducibility combined with largest estimates of CIMT progression measured with high precision and are to be recommended in this population.

Urban legend versus rural reality: patients' experience of attendance at accident and emergency departments in west Wales.

OBJECTIVES: To investigate why and how patients decide to attend accident and emergency (A&E) departments, and to assess their satisfaction with the experience, in a predominantly rural west Wales population. METHODS: This was a semi-structured follow up telephone interview of patients who walked in to A&E in one of four general hospitals in west Wales and were triaged as Manchester Triage score 4 or 5. Patients were recruited by nurses during the period July-November 2002. The study sample consisted of 176 male and 145 female patients, mean (SD) age 36.6 (20.0) years. The main outcome measure was a quantitative and qualitative description of the recalled experiences of A&E attenders, the circumstances of their attendance, and their satisfaction with the experience. RESULTS: Of the study sample, 78% attended with injury or illnesses of recent origin, and 50% with actual or presumed musculoskeletal injury, 73% of which were sustained within 10 miles of home. Travel to hospital was by private transport for 86%, average distance 7.4 miles. The majority (90%) were registered with a local GP, but 32% felt A&E was the obvious choice, and a further 44% considered their GP inaccessible to their needs. Patients' reasons for seeking health care at A&E were similar to those described in an English urban study. Waiting times were rarely excessive; 80% left within 2 hours, and patient satisfaction was generally high. Among the 87 patients (27%) who reported a less satisfactory experience, 48 (55%) of these complained of dismissive attitudes of doctors. CONCLUSIONS: Anecdotal accounts of abuse of A&E services and unreasonable patient expectations gain the status of "urban legends" within the medical profession. Among the predominantly settled rural population in west Wales, there is little evidence of unreasonable patient expectations, and most patients report high satisfaction levels. Patients' bad experiences most frequently arise from a dismissive attitude on the part of medical staff. These attitudes are often consequent on an A&E culture that views some patients' attendances as less appropriate than others.

Receiving mass casualties at sea: the capabilities of the primary casualty receiving facility.

Exercise Aurora (May-June 2004) off the eastern seaboard of the United States provided an opportunity, on several occasions, to test the ability of the PCRF to cope with large numbers of "casualties" arriving simultaneously. This article reviews the role of the PCRF, its facilities and capabilities, and how these are currently utilised to handle mass casualties. Some of the valuable lessons identified from Exercise Aurora are briefly discussed.

Ambient neighbourhood noise and children's mental health.

OBJECTIVES: To investigate the relation between typical ambient noise levels (highway, rail, road) and multiple mental health indices of school children considering psychosocial and biological risk factors as potential moderators. METHODS: With a two stage design strategy (representative sample and extreme sample) two cross sectional samples (n=1280; n=123) of primary school children (age 8-11) were studied. Individual exposure to noise at home was linked with two indices of mental health (self reporting by the child on a standard scale and rating by the teacher of classroom adjustment on a standard scale). Noise exposure was modelled firstly according to Austrian guidelines with the aid of a geographical information system and then calibrated and corrected against measurements from 31 locations. Information on potential confounders and risk factors was collected by mothers and controlled in regression modelling through a hierarchical forward stepping procedure. Interaction terms were also analysed to examine subgroups of children at risk-for example, low birth weight and preterm birth. RESULTS: Noise exposure was significantly associated in both samples with classroom adjustment ratings. Child self reported mental health was significantly linked to ambient noise only in children with a history of early biological risk (low birth weight and preterm birth). CONCLUSIONS: Exposure to ambient noise was associated with small decrements in children's mental health and poorer classroom behaviour. The correlation between mental health and ambient noise is larger in children with early biological risk.

Arterial distensibility and physical activity in the ARIC study.

PURPOSE: Arterial distensibility decreases with age. This decrease may be associated with the initiation and/or progression of hypertension and atherosclerosis and may be attenuated by positive lifestyle habits, including habitual physical activity. We tested the hypothesis that self-reported sport, leisure, and work physical activity is associated with greater arterial distensibility (i.e., carotid artery pulsatile diameter changes). METHODS: The Atherosclerosis Risk in Communities (ARIC) study assessed left common carotid arterial diameters and intimal-medial wall thickness (IMT) using B-mode ultrasound techniques, in 10,644 African-American and white men and women aged 45-64 yr and free of cardiovascular disease. RESULTS: Work activity, but not sports or leisure activity, was weakly associated with greater arterial distensibility in an ANCOVA model adjusted for blood pressure and other covariates (diastolic arterial diameter, pulse pressure, pulse pressure squared, age, race, sex, smoking, dietary fat intake, height, education, and clinical center) (P for linear trend = 0.03). Vigorous sports activity was weakly positively associated with arterial distensibility (arterial diameter change (mean +/- SE in mm) 0.42 +/- 0.004 vs 0.41 +/- 0.002 for the 12.7% of participants reporting any vs no vigorous activity, P = 0.02), and this association was not attenuated by adjustment for IMT, body mass index, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, or diabetes. Repeated analyses with traditional arterial stiffness indices showed similar findings for vigorous but not work activity. CONCLUSION: In contrast to several smaller studies, these findings do not support the hypothesis that habitual physical activity has a strong, consistent positive effect on arterial distensibility.

Acoustic shadowing on B-mode ultrasound of the carotid artery predicts ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) study.

BACKGROUND AND PURPOSE: We examined the relationship of carotid artery lesions (CALs), with and without acoustic shadowing (AS), to incident ischemic stroke events in the Atherosclerosis Risk in Communities study cohort. METHODS: The study population consisted of 13 123 men and women aged 45 to 64 years, and free of stroke, examined during 1986-1989. Over an average follow-up time of 8.0 years, 226 incident ischemic stroke cases (thromboembolic brain infarctions) were identified and classified by a standardized protocol. Three levels of exposure were defined on the basis of the presence of B-mode ultrasound-detected CALs and AS in a 3-cm segment of the carotid arteries centered at the bifurcation. RESULTS: The hazard ratio for ischemic stroke adjusted for age, ethnicity, and study site for women with a CAL without AS, compared with those without a CAL, was 1.92 (95% CI, 1.23, 3.01), and the hazard ratio comparing those with a CAL with AS with those without a CAL was 4.01 (95% CI, 2.28, 7.06). The corresponding hazard ratios for men were 1.99 (95% CI, 1.36, 2.91) and 2.23 (95% CI, 1.32, 3.79). Although adjustment for diabetes, hypertension medication, systolic blood pressure, left ventricular hypertrophy score, fibrinogen, von Willebrand factor antigen, and smoking status attenuated these associations somewhat, when compared with no evidence of CALs, CALs with AS remained statistically significant predictors of ischemic stroke in women, while CALs without AS were predictive of ischemic stroke in men. CONCLUSIONS: B-mode ultrasound-detected CALs and AS serve as markers of atherosclerosis and thus are predictive of ischemic stroke.

Radiologic determination of intravascular volume status using portable, digital chest radiography: a prospective investigation in 100 patients.

OBJECTIVE: To answer the following questions: Can the digital chest roentgenogram (CXR) be used to differentiate patients' volume status? Do clinical data alter radiologists' accuracy in interpreting the digital CXR? DESIGN: Prospective cohort study. SETTING: Nine adult intensive care units of a tertiary care medical center. PATIENTS: One hundred thirty-five consecutive patients with pulmonary artery catheters, of whom 35 were excluded because of unacceptable pulmonary artery occlusion pressure (PAOP) tracings. METHODS: Each patient had a portable, anteroposterior, supine digital CXR. Clinicians evaluated volume status and then measured hemodynamic data within 1 hr of the CXR. Digital CXRs were independently interpreted on two separate occasions (with and without clinical information) by three experienced chest radiologists, and these interpretations were compared with hemodynamic data. RESULTS: Of the 100 patients, 39 had PAOP >18 mm Hg, whereas 61 had PAOP <18 mm Hg. Radiologists' accuracy in differentiating volume status increased with incorporation of clinical data (56% without vs. 65% with clinical data, p =.009). Using objective receiver operating characteristic-derived cutoffs of 70 mm for vascular pedicle width and 0.55 for cardiothoracic ratio, radiologists' accuracy in differentiating PAOP >18 mm Hg from PAOP <18 mm Hg was 70%. The intrareader and the inter-reader correlation coefficients were very high. The likelihood ratio of the CXR in determining volume status using the objective vascular pedicle width and cardiothoracic ratio measures was 3.1 (95% confidence interval, 1.9-6.0), significantly higher than subjective CXR interpretations with and without clinical data (p <.001). CONCLUSIONS: Differentiating intravascular volume status with portable, supine, digital CXRs may be improved by using objective cutoffs of vascular pedicle width >70 mm and cardiothoracic ratio >0.55 or by incorporating clinical data.

Acoustic shadowing on B-mode ultrasound of the carotid artery predicts CHD.

The relationship between carotid artery lesions (CALs), with and without acoustic shadowing (AS) as an index of arterial mineralization, and incident coronary heart disease (CHD) was examined in the Atherosclerosis Risk in Communities study cohort. Among 12,375 individuals, ages 45-64 years, free of CHD at baseline, 399 CHD events occurred between 1987-1995. In a 3-cm segment centered at the carotid bifurcation, CALs with and without AS were identified by B-mode ultrasound (US). After adjustment for the major CHD risk factors, the CHD hazard ratio (HR) for women with CAL without AS compared to women without CAL was 1.78 (95% CI: 1.22, 2.60) and the HR comparing women with CAL with AS to women with CAL without AS was 1.73 (95% CI: 1.07, 2.80). Corresponding HRs for men were 1.59 (95% CI: 1.22, 2.07) and 1.04 (95% CI: 0.72, 1.51). CALs predicted CHD events; this association was stronger for mineralized CALs in women, but not men.

Community noise exposure and stress in children.

Although accumulating evidence over the past two decades points towards noise as an ambient stressor for children, all of the data emanate from studies in high-intensity, noise impact zones around airports or major roads. Extremely little is known about the nonauditory consequences of typical, day-to-day noise exposure among young children. The present study examined multimethodological indices of stress among children living under 50 dB or above 60 dB (A-weighted, day-night average sound levels) in small towns and villages in Austria. The major noise sources were local road and rail traffic. The two samples were comparable in parental education, housing characteristics, family size, marital status, and body mass index, and index of body fat. All of the children were prescreened for normal hearing acuity. Children in the noisier areas had elevated resting systolic blood pressure and 8-h, overnight urinary cortisol. The children from noisier neighborhoods also evidenced elevated heart rate reactivity to a discrete stressor (reading test) in the laboratory and rated themselves higher in perceived stress symptoms on a standardized index. Furthermore girls, but not boys, evidenced diminished motivation in a standardized behavioral protocol. All data except for the overnight urinary neuroendocrine indices were collected in the laboratory. The results are discussed in the context of prior airport noise and nonauditory health studies. More behavioral and health research is needed on children with typical, day-to-day noise exposure.

"She looked just like me." A domestic violence learning module.

This paper describes a 22-hour domestic violence learning module that is incorporated into the psychosocial course for seniors in a baccalaureate nursing program. As part of their learning experiences, students attend circuit court, meet with judges, and accompany advocacy workers. Additionally, they attend group therapy sessions with both the victims and perpetrators of abuse. Students keep journals reflecting their thoughts, feelings, and reactions throughout the experiences. Thematic analysis of these journal entries revealed five common themes. Students recognized their encounters in clinical situations as frightening and emotionally difficult, expressed surprise at their reactions to perpetrators, identified with victims, wrestled with issues of good and bad, and reported that stereotypes about victims and perpetrators had been incorrect. Debriefings and support by faculty are important for students throughout the experience.

Stress and open-office noise.

Forty female clerical workers were randomly assigned to a control condition or to 3-hr exposure to low-intensity noise designed to simulate typical open-office noise levels. The simulated open-office noise elevated workers' urinary epinephrine levels, but not their norepinephrine or cortisol levels, and it produced behavioral aftereffects (fewer attempts at unsolvable puzzles) indicative of motivational deficits. Participants were also less likely to make ergonomic, postural adjustments in their computer work station while working under noisy, relative to quiet, conditions. Postural invariance is a risk factor for musculoskeletal disorder. Although participants in the noise condition perceived their work setting as significantly noisier than those working under quiet conditions did, the groups did not differ in perceived stress. Potential health consequences of long-term exposure to low-intensity office noise are discussed.

Cross-cultural differences in tolerance for crowding: fact or fiction?

It is widely believed that cultures vary in their tolerance for crowding. There is, however, little evidence to substantiate this belief, coupled with serious shortcomings in the extant literature. Tolerance for crowding has been confused with cultural differences in personal space preferences along with perceived crowding. Furthermore, the few studies that have examined cultural variability in reactions to crowding have compared subgroup correlations, which is not equivalent to a statistical interaction. Although the authors found a statistical interaction indicating that Asian Americans and Latin Americans differ in the way they perceive crowding in comparison to their fellow Anglo-American and African American citizens, all four ethnic groups suffer similar, negative psychological distress sequelae of high-density housing. These results hold independently of household income.

Housing quality and mental health.

This study examined the potential link between housing quality and mental health. First, the development of a psychometrically sound, observer-based instrument to assess physical housing quality in ways conceptually relevant to psychological health is reported. Then 2 different studies, including a prospective longitudinal design, demonstrate that physical housing quality predicts mental health. Possible underlying psychosocial processes for the housing quality-psychological distress link are discussed.