Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors.

BACKGROUND: Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. METHODS: With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. RESULTS: A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021). CONCLUSIONS: Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

Increasing acceptability and uptake of voluntary male medical circumcision in Zambia: implementing and disseminating an evidence-based intervention.

Voluntary medical male circumcision (VMMC) uptake in Africa could prevent 3.4 million HIV infections across a 10 year span. In Zambia, however, ~80 per cent of uncircumcised men report no interest in undergoing VMMC. The Spear & Shield (S&S) intervention has been shown to be more effective than control or observation of only conditions at increasing the number of VMMCs. This study identified predictors of S&S implementation success or failure to create an "early warning" system to enable remedial action during implementation. Participants were n = 48 staff members from 12 community health facilities conducting the S&S program in Lusaka Province, Zambia. Quantitative assessments included demographics, provider attitudes, barriers to research uptake, staff burnout, and organizational readiness. Qualitative interviews were also conducted and quantified for analysis using the Consolidated Framework for Implementation Research (CFIR). Two-thirds (66%) of staff were women with a mean age of 37.67 years (SD = 7.51). Quantitatively, staff performance (p = .033) and decreased levels of staff burnout (p = .025) were associated with S&S implementation success. Qualitatively, constructs such as improved planning, executing, and self-reflection and evaluation were associated with S&S implementation success (p = .005). Identifying these factors facilitated remedial action across health facilities. This study illustrates the utility of the CFIR to guide program decision making in VMMC implementation in the Zambian context. Early identification of challenges to implementation may enable remedial action to enhance the likelihood of program sustainability. Effective monitoring strategies for HIV prevention interventions may thus enhance dissemination, implementation, and sustainability goals to bridge research and practice.

The Role of Artificial Intelligence in Diagnostic Radiology: A Survey at a Single Radiology Residency Training Program.

PURPOSE: Advances in artificial intelligence applied to diagnostic radiology are predicted to have a major impact on this medical specialty. With the goal of establishing a baseline upon which to build educational activities on this topic, a survey was conducted among trainees and attending radiologists at a single residency program. METHODS: An anonymous questionnaire was distributed. Comparisons of categorical data between groups (trainees and attending radiologists) were made using Pearson χ2 analysis or an exact analysis when required. Comparisons were made using the Wilcoxon rank sum test when the data were not normally distributed. An α level of 0.05 was used. RESULTS: The overall response rate was 66% (69 of 104). Thirty-six percent of participants (n = 25) reported not having read a scientific medical article on the topic of artificial intelligence during the past 12 months. Twenty-nine percent of respondents (n = 12) reported using artificial intelligence tools during their daily work. Trainees were more likely to express doubts on whether they would have pursued diagnostic radiology as a career had they known of the potential impact artificial intelligence is predicted to have on the specialty (P = .0254) and were also more likely to plan to learn about the topic (P = .0401). CONCLUSIONS: Radiologists lack exposure to current scientific medical articles on artificial intelligence. Trainees are concerned by the implications artificial intelligence may have on their jobs and desire to learn about the topic. There is a need to develop educational resources to help radiologists assume an active role in guiding and facilitating the development and implementation of artificial intelligence tools in diagnostic radiology.

Implementation of Lifestyle Modification Program Focusing on Physical Activity and Dietary Habits in a Large Group, Community-Based Setting.

BACKGROUND: Lifestyle modification programs improve several health-related behaviors, including physical activity (PA) and nutrition. However, few of these programs have been expanded to impact a large number of individuals in one setting at one time. Therefore, the purpose of this study was to determine whether a PA- and nutrition-based lifestyle modification program could be effectively conducted using a large group format in a community-based setting. METHOD: One hundred twenty-one participants enrolled in a 16-week, community-based lifestyle modification program and separated in small teams of 13 to 17 individuals. Height, weight, fruit and vegetable (FAV) consumption, physical fitness, and several psychosocial measures were assessed before and after the program. RESULTS: Significant improvements in 6-minute walk distance (+68.3 m; p < .001), chair stands (+6.7 repetitions; p < .001), FAV servings (+1.8 servings/day; p < .001), body weight (-3.2 lbs; p < .001), as well as PA social support and eating habits self-efficacy were observed. Our lifestyle modification program was also successful in shifting participants to higher levels of stages of change for nutrition and PA, increasing overall levels of self-efficacy for healthy eating, and improving levels of social support for becoming more active. CONCLUSIONS: A lifestyle modification program can be successfully implemented in a community setting using a large group format to improve PA and FAV attitudes and behaviors.

A cross-sectional survey of cadmium biomarkers and cigarette smoking.

Cadmium contamination of tobacco may contribute to the health hazards of cigarette smoking. The 2005-2012 United States National Health and Nutrition Examination Survey data provided a unique opportunity to conduct a cross-sectional survey of cadmium biomarkers and cigarette smoking. Among a sample of 6761 participants, we evaluated mean differences and correlations between cadmium biomarkers in the blood and urine and characteristics of never, former and current smokers. We found statistically significant differences in mean cadmium biomarker levels between never and former smokers as well as between never and current smokers. In current smokers, duration in years had a higher correlation coefficient with urinary than blood cadmium levels. In contrast, number of cigarettes smoked per day had a higher correlation coefficient with blood than urinary cadmium levels. These data suggest that blood and urine cadmium biomarker levels differ by duration and dose. These findings should be considered in evaluating any association between cadmium and smoking related diseases, especially cardiovascular disease.

A Wellness Program for Cancer Survivors and Caregivers: Developing an Integrative Pilot Program with Exercise, Nutrition, and Complementary Medicine.

The Integrative Wellness Program (IWP) at the University of Miami Sylvester Comprehensive Cancer Center (SCCC) sought to provide integrative wellness education to cancer patients, survivors, and caregivers by offering instruction in exercise, nutrition, and complementary and alternative medicine. The objective of this study was to assess the impact of the IWP on the overall wellness of the individuals participating in the program. Three different 10-week versions of the IWP were conducted over a 1-year period. Each session focused on a different wellness topic presented through interactive lectures and applied activities. A series of self-report questionnaires were administered at baseline and again at the completion of the program to assess improvements in physical activity levels, dietary habits, sleep hygiene, and quality of life. Participants were generally older, Caucasian, female, had higher levels of education, and still currently receiving treatment. Significant changes were observed in two measures: Starting the Conversation (-2.0 ± 2.40, p = .037) and the Sticking To It subscale of the Self-Efficacy and Eating Habits Survey (1.7 ± 1.22, p = .0013). A trend for improvement in the Reducing Fat subscale of the Self-Efficacy Eating Habits (0.44 ± 0.60, p = .056) was also observed. Participant satisfaction surveys indicated high levels of satisfaction and applicability of the material presented. The significant improvements detected related to dietary habits, combined with the responses from the participant satisfaction surveys, suggest that the IWP was well received and can positively impact the overall wellness of cancer patients, survivors, and their caregivers.

Modelling optimum use of attractive toxic sugar bait stations for effective malaria vector control in Africa.

BACKGROUND: The development of insecticide resistance and the increased outdoor-biting behaviour of malaria vectors reduce the efficiency of indoor vector control methods. Attractive toxic sugar baits (ATSBs), a method targeting the sugar-feeding behaviours of vectors both indoors and outdoors, is a promising supplement to indoor tools. The number and configuration of these ATSB stations needed for malaria control in a community needs to be determined. METHODS: A hypothetical village, typical of those in sub-Saharan Africa, 600 × 600 m, consisting of houses, humans and essential resource requirements of Anopheles gambiae (sugar sources, outdoor resting sites, larval habitats) was simulated in a spatial individual-based model. Resource-rich and resource-poor environments were simulated separately. Eight types of configurations and different densities of ATSB stations were tested. Anopheles gambiae population size, human biting rate (HBR) and entomological inoculation rates (EIR) were compared between different ATSB configurations and densities. Each simulated scenario was run 50 times. RESULTS: Compared to the outcomes not altered by ATSB treatment in the control scenario, in resource-rich and resource-poor environments, respectively, the optimum ATSB treatment reduced female abundance by 98.22 and 91.80 %, reduced HBR by 99.52 and 98.15 %, and reduced EIR by 99.99 and 100 %. In resource-rich environments, n × n grid design, stations at sugar sources, resting sites, larval habitats, and random locations worked better in reducing vector population and HBRs than other configurations (P < 0.0001). However, there was no significant difference of EIR reductions between all ATSB configurations (P > 0.05). In resource-poor environments, there was no significant difference of female abundances, HBRs and EIRs between all ATSB configurations (P > 0.05). The optimum number of ATSB stations was about 25 for resource-rich environments and nine for resource-poor environments. CONCLUSIONS: ATSB treatment reduced An. gambiae population substantially and reduced EIR to near zero regardless of environmental resource availability. In resource-rich environments, dispersive configurations worked better in reducing vector population, and stations at or around houses worked better in preventing biting and parasite transmission. In resource-poor environments, all configurations worked similarly. Optimum numbers of bait stations should be adjusted according to seasonality when resource availability changes.

Ethnicity, Household Food Security, and Nutrition and Activity Patterns in Families With Preschool Children.

OBJECTIVE: This study evaluated the relationship between food security and child nutritional intake, sedentary behavior, and body mass index (BMI) and potential moderation by ethnic subgroup membership. DESIGN: Cross-sectional data analysis from baseline data of a preschool intervention trial. SETTING: Twenty-eight subsidized child care centers in Miami-Dade County, FL. PARTICIPANTS: Children ages 2 to 5 (n = 1,211) and their caregivers. MAIN OUTCOME MEASURE: The BMI percentile and the following 4 factors (via confirmatory factor analysis): food security, consumption of fruits/vegetables, consumption of unhealthy foods, and sedentary behaviors. ANALYSIS: Separate linear mixed models tested relationships between food security and main outcome measures with an interaction term to test for possible moderation by ethnicity. RESULTS: Results indicated a significant relationship (P < .05) between food security and child consumption of fruit/vegetables, consumption of unhealthy foods, and sedentary behavior, but not with BMI percentile. With greater food security, Haitians reported greater consumption of fruit/vegetables and sedentary behavior. With greater food security, Cubans and non-Hispanic whites reported less consumption of unhealthy foods, while Haitians reported greater consumption. CONCLUSIONS AND IMPLICATIONS: Results showed higher food security was associated with higher consumption of fruit/vegetables, consumption of unhealthy foods, and sedentary behavior, but this was moderated by ethnicity. Implications for healthy weight interventions among low-income preschoolers should focus on the importance of food security and tailor intervention strategies for diverse ethnic groups accordingly.

A spatial individual-based model predicting a great impact of copious sugar sources and resting sites on survival of Anopheles gambiae and malaria parasite transmission.

BACKGROUND: Agent-based modelling (ABM) has been used to simulate mosquito life cycles and to evaluate vector control applications. However, most models lack sugar-feeding and resting behaviours or are based on mathematical equations lacking individual level randomness and spatial components of mosquito life. Here, a spatial individual-based model (IBM) incorporating sugar-feeding and resting behaviours of the malaria vector Anopheles gambiae was developed to estimate the impact of environmental sugar sources and resting sites on survival and biting behaviour. METHODS: A spatial IBM containing An. gambiae mosquitoes and humans, as well as the village environment of houses, sugar sources, resting sites and larval habitat sites was developed. Anopheles gambiae behaviour rules were attributed at each step of the IBM: resting, host seeking, sugar feeding and breeding. Each step represented one second of time, and each simulation was set to run for 60 days and repeated 50 times. Scenarios of different densities and spatial distributions of sugar sources and outdoor resting sites were simulated and compared. RESULTS: When the number of natural sugar sources was increased from 0 to 100 while the number of resting sites was held constant, mean daily survival rate increased from 2.5% to 85.1% for males and from 2.5% to 94.5% for females, mean human biting rate increased from 0 to 0.94 bites per human per day, and mean daily abundance increased from 1 to 477 for males and from 1 to 1,428 for females. When the number of outdoor resting sites was increased from 0 to 50 while the number of sugar sources was held constant, mean daily survival rate increased from 77.3% to 84.3% for males and from 86.7% to 93.9% for females, mean human biting rate increased from 0 to 0.52 bites per human per day, and mean daily abundance increased from 62 to 349 for males and from 257 to 1120 for females. All increases were significant (P < 0.01). Survival was greater when sugar sources were randomly distributed in the whole village compared to clustering around outdoor resting sites or houses. CONCLUSIONS: Increases in densities of sugar sources or outdoor resting sites significantly increase the survival and human biting rates of An. gambiae mosquitoes. Survival of An. gambiae is more supported by random distribution of sugar sources than clustering of sugar sources around resting sites or houses. Density and spatial distribution of natural sugar sources and outdoor resting sites modulate vector populations and human biting rates, and thus malaria parasite transmission.

Catechol-o-methyltransferase polymorphisms predict opioid consumption in postoperative pain.

BACKGROUND: Previous studies have associated the catechol-O-methyltransferase (COMT) enzyme rs4680 polymorphism with opioid consumption in the treatment of chronic cancer pain. In this study, we evaluated the association between COMT rs4680 and rs4818 polymorphisms and opioid consumption in the acute postoperative period after a nephrectomy. METHODS: Opioid consumption and pain scores were evaluated in 152 patients for 48 hours after nephrectomy. The genotype of each patient was determined using polymerase chain reaction on DNA extracted from blood samples. The association between rs4680 and rs4818 genotypes and opioid consumption was evaluated using general linear model regression analysis. All P values and confidence intervals were Bonferroni corrected for the 3 comparisons among genotypes. RESULTS: In the 24-hour period after surgery (COMT rs4680), patients homozygous for the variant Val/Val consumed 36% (95% confidence interval, 31%-41%) more opioids than patients homozygous for the Met/Met group (P = 0.009). No statistically significant differences among the 3 genotype groups were noted for pain scores or emesis medication use in the first 24 hours after surgery. There was a statistically significant increase in emesis medication use in patients possessing the CC genotype of rs4818 when compared to patients carrying the GG genotypes (P = 0.035). In the 6- to 48-hour postsurgery period, there was significantly higher opioid consumption in the high-activity homozygotes Val/Val than in the homozygous Met/Met group for COMT rs4680 (0-6 h: P = 0.005; 0-12 h: P = 0.015; 0-24 h: P = 0.015; and 0-48 h: P = 0.023). Patients in the homozygous GG group COMT rs4818 single nucleotide polymorphism showed statistically significant differences in opioid consumption in the first 6 hours after nephrectomy compared with heterozygous CG patients (P = 0.02). CONCLUSIONS: The genetic variant of the COMT rs4680 single nucleotide polymorphism is associated with variability in opioid consumption in postoperative nephrectomy patients. The COMT rs4818 polymorphism may prove useful in predicting emesis medication use postoperatively.

Role modeling as an early childhood obesity prevention strategy: effect of parents and teachers on preschool children's healthy lifestyle habits.

OBJECTIVE: To assess the effectiveness of a child care center-based parent and teacher healthy lifestyle role-modeling program on child nutrition and physical activity outcomes. METHODS: Child care centers (N = 28) serving low-income families were randomized to intervention or control arms. Intervention centers (N = 12) implemented (1) menu modifications, (2) a child's healthy lifestyle curriculum, and (3) an adult (teacher- and parent-focused) healthy lifestyle role-modeling curriculum. Control centers (N = 16) received an attention control safety curriculum. Nutrition and physical activity data were collected at the beginning (T1) and at the end (T2) of the school year. Exploratory factor analysis identified positive and negative nutrition and physical activity practices by children, parents, and teachers. RESULTS: Intervention parents' baseline (ß = .52, p < .0001) and school year consumption (ß = .47, p < .0001) of fruits/vegetables significantly increased their children's consumption of fruits/vegetables from T1 to T2. Intervention parents significantly influenced a decrease in children's junk food consumption (ß = -.04, p < .05), whereas control parents significantly influenced an increase in their children's junk food consumption (ß = .60, p < .001) from T1 to T2. Control children showed a significant increase in junk food consumption (ß = .11, p = .01) and sedentary behavior (ß = .09, p < .005) from T1 to T2. Teachers did not significantly influence preschool-age children's nutrition or physical activity patterns from T1 to T2. CONCLUSIONS: Parent nutrition and physical activity patterns significantly influence their preschool-age children's consumption of fruits/vegetables, junk food, and level of sedentary behavior. Future obesity prevention intervention efforts targeting this age group should include parents as healthy lifestyle role models for their children.

Implementation of HIV prevention interventions in resource limited settings: the partner project.

Evidence-based HIV prevention interventions have been translated to a variety of contexts across sub-Saharan Africa. Non-specialized community health center (CHC) staff members have been successfully engaged to deliver the interventions, which can be integrated into pre-existing HIV service programs in community-based health care delivery sites. This manuscript describes the process of implementing the Partner Project, a couples HIV risk reduction intervention, and examines the ability of CHC staff to achieve risk reduction outcomes comparable to those of the highly-trained research staff. The Partner Project was implemented within the HIV Counseling and Testing program in 6 urban community health clinics in Lusaka, Zambia. One hundred ninety-seven HIV-seroconcordant and -discordant couples were sequentially enrolled to the control group or to receive the intervention from partner research or CHC staff members. Couple members completed assessments on condom use, alcohol use, and intimate partner violence (IPV) at baseline, 6, and 12 months follow-up. Sexual barrier use outcomes achieved by the CHC staff were comparable to or better than those achieved by the Partner Project research staff, and both were superior to the control group. A reduction in IPV was observed for the entire sample, although no change in alcohol use was observed. Implementation of HIV prevention interventions at the community level should take advantage of existing resources available within the CHC staff. This is especially relevant in resource limited settings as consideration of the financial and clinical requirements of intervention programs is essential to the achievement of successful program implementation.

Acceptability, knowledge, beliefs, and partners as determinants of Zambian men's readiness to undergo medical male circumcision.

There is limited information about the influence of partners on medical male circumcision (MMC) uptake. This study aimed to evaluate attitudes, knowledge, and preferences about MMC among men and their partners, and their relative impact on male readiness to undergo the MMC procedure. Male participants (n = 354) and their partners (n = 273) were recruited from community health centers in Lusaka, Zambia. Men reported their readiness to undergo MMC, and both men and women were assessed regarding their attitudes and knowledge regarding MMC. Men who had discussed MMC with their partners, those who endorsed MMC for HIV risk reduction, and those viewing MMC as culturally acceptable reported increased readiness to undergo MMC. Additionally, endorsement of MMC by female partners was associated with increased men's readiness. Results support promotion of cultural acceptability of MMC, and efforts to increase MMC uptake may benefit from incorporating partners in the decision making process.

Determination of the safe range of graft size mismatch using body surface area index in deceased liver transplantation.

In live donor liver transplantation, rigorous standardized criteria for matching of liver volume between donor and recipient have prevented graft loss because of size mismatch. In deceased whole liver transplantation, the safe donor-recipient size mismatch range remains unknown. We developed a multivariate survival model (generalized additive model) to estimate hazard risk of body surface area index (BSAi) for 3-year graft survival using data derived from the national registry database between 2005 and 2010. BSAi was calculated by BSA of donor divided by BSA of recipient. 24 509 patients were included in the analysis. Small-for-size (SFS) grafts with BSAi less than 0.78 had a significant impact on graft dysfunction with progressive increase of hazard risk toward the lowest end and a higher incidence of primary graft nonfunction and vascular thrombosis. Large-for-size (LFS) grafts with BSAi greater than 1.24 had a significant impact on graft dysfunction with progressive increase of hazard risk toward the largest end. Our findings suggest that donor grafts with BSAi < 0.78 could be considered 'SFS' and donor grafts with BSAi > 1.24 could be considered 'LFS', with both extremes resulting in decreased graft survival. Therefore, BSAi > 0.78 and <1.24 appears to be a safe range to avoid adverse outcome associated with size mismatch.

Ultrasound assessment of the vertebral level of the intercristal line in pregnancy.

BACKGROUND: The intercristal line is known to most frequently cross the L4 spinous process or L4-5 interspace; however, it is speculated to be positioned higher during pregnancy because of the exaggerated lumbar lordosis. Clinical estimation of vertebral levels relying on the use of the intercristal line has been shown to often be inaccurate. We hypothesized that the vertebral level of the intercristal line determined by palpation would be higher than the level determined by ultrasound in pregnant women. METHODS: Fifty-one term pregnant patients were recruited. Two experienced anesthesiologists performed estimates of the position of the intercristal line by palpation. Using ultrasound, another anesthesiologist who was blinded to the clinical estimates, determined the position of the superior border of the iliac crest in the transverse and longitudinal planes and then identified the lumbar vertebral levels. The vertebral level at which the clinical estimates of the intercristal line crossed the spine was recorded and compared with the ultrasound-determined level of the superior border of the iliac crest. RESULTS: The clinical estimates of the spinal level of the intercristal line agreed with the ultrasound measurement 14% of the time (14 of 101; 95% confidence interval [CI]: 8%, 22%). The clinical estimates were 1 level higher than the ultrasound measurement 23% of the time (23 of 101; 95% CI: 16%, 32%) and >1 level higher 25% of the time (25 of 101; 1-tailed 95% CI: >18%). The distribution of the clinical estimates found clinicians locating the intercristal line at L3 or L3-4 54% of the time (54 of 101; 95% CI: 44%, 63%) and at L2-3 or higher 27% of the time (27 of 101; 1-tailed 95% CI: >20%). CONCLUSION: The anatomical position of the intercristal line was at L3 or higher in at least 6% of term pregnant patients using ultrasound. Clinical estimates were found to be ≥1 vertebral level higher than the anatomical position determined by ultrasound at least 40% of the time. This disparity may contribute to misidentification of lumbar interspaces and increased risk of neurologic injury during neuraxial anesthesia.

Increasing rates of melanoma among nonwhites in Florida compared with the United States.

OBJECTIVE: To compare melanoma trends within Florida with national melanoma trends from 1992 through 2004. An analysis of state and national melanoma trends is critical for the identification of high-risk regions of the country. DESIGN: Data from the Florida Cancer Data System (FCDS) and Surveillance, Epidemiology, and End Results (SEER) were evaluated to determine age-adjusted and race/ethnicity- and sex-specific invasive cutaneous melanoma incidence trends for 1992 through 2004 using joinpoint regression analysis. Standardized incidence rate ratios (SIRRs) were computed to compare Florida with the United States. PATIENTS: A population of 109 633 patients with invasive melanoma was evaluated: 73 206 (66.8%) from SEER and 36 427 (33.2%) from FCDS. MAIN OUTCOME MEASURES: Melanoma incidence and change in melanoma rates over time. RESULTS: The incidence of melanoma among male Hispanic patients residing in Florida was 20% higher than that of their male counterparts in the SEER catchment areas (SIRR, 1.2; 95% confidence interval [CI], 1.1-1.4). Conversely, the incidence of melanoma among female Hispanic patients residing in Florida was significantly lower than that in SEER (SIRR, 0.7; 95% CI, 0.7-0.8). Differences in melanoma incidence were identified in female non-Hispanic black (NHB) patients in Florida who had a 60% significantly higher incidence of melanoma compared with female NHB patients in SEER (SIRR, 1.6; 95% CI, 1.3-2.0). CONCLUSION: These findings suggest an emerging public health concern in race/ethnic subgroups that were previously understudied.

Changes in youth cigarette use following the dismantling of an antitobacco media campaign in Florida.

We examined the association of the termination of a successful youth-targeted antitobacco media campaign ("truth") and changes in smoking rates among youths aged 12-17 years in Florida. Six telephone-based surveys were completed during the active media campaign (1998-2001), and 2 postcampaign surveys were completed in 2004 and 2006 (each n approximately 1,800). Prevalence of current smoking among youth observed during the campaign continued to decrease in the first postcampaign survey; however, by the second follow-up survey, youth smoking rates had increased significantly for youth aged 16 years or older. Our findings support the need for consistent antitobacco messaging to reduce the prevalence of youth smoking.

Evaluation of an immunosuppressant side effect instrument.

BACKGROUND: Clinicians continue to be compelled to evaluate the impact of immunosuppressive medication side effects on the quality of life of transplant recipients. We Were asked to develop an instrument to measure side effects in immunosuppressed transplant recipients. OBJECTIVE: To construct an instrument that measures the impact and severity of side effects of immunosuppressive medications used in transplantation and to assess the reliability and validity of the newly developed instrument called the Memphis Survey. DESIGN: The instrument was constructed by a panel of physicians, nurses, and pharmacists with experience in treating transplant recipients. A small group of kidney transplant recipients (n= 13) provided pilot data for refining and testing the instrument. A national sample of kidney, liver, and heart transplant recipients (n = 505) provided data that were used to further develop the instrument. ANALYSIS: Factor analysis was used to determine the psychological dimensions underlying the instrument and to guide the construction of scales from the survey items. The instrument scales were then computed from the dataset of 505 transplant recipients to quantify the impact of immunosuppressant side effects on the quality of life of transplant recipients. RESULTS AND CONCLUSION: Analyses showed the final instrument scales to be valid and reliable. Exploratory analysis suggests the need for further testing of the instrument to determine gender differences.

Reliability of histopathologic assessment for the differentiation of recurrent hepatitis C from acute rejection after liver transplantation.

Histopathologic assessment is considered essential for the differentiation of recurrent hepatitis C (RHC) from acute cellular rejection (ACR) after liver transplantation (LT); however, there is limited information regarding its reliability. The aim of this study was to determine the interobserver and intraobserver agreement of the histopathologic diagnosis of RHC vs. ACR, and to determine the reliability of specific histopathologic features for the differentiation of RHC from ACR. Liver biopsy specimens from 105 consecutive patients transplanted for hepatitis C virus (HCV)-related liver disease were studied retrospectively. All the biopsies were performed for evaluation of abnormal liver enzymes within the 1st year after LT. The slides were blindly coded and assessed by 5 liver-transplant pathologists, practicing at 3 medical centers. The pathologists were asked to render a diagnosis, and determine the severity of the disease. Four of the pathologists were asked to determine the presence and severity of 36 histopathologic features. A total of 34 of the samples were then blindly resubmitted to each of the 4 pathologists to determine the intraobserver agreement. There was a slight agreement (kappa = .12) among the 5 pathologists on the histopathologic diagnosis. All 5 pathologists were in agreement on the diagnosis of RHC in only 5 patients (5%) and on the diagnosis of ACR in only 2 patients (2%). The best agreement among any 4 pathologists was fair (kappa = .20). Slight to moderate agreement occurred on the main histological features considered to be important in the diagnosis of ACR. Intraobserver agreement ranged from slight (kappa = .19) to moderate (kappa = .42) among 4 pathologists. In conclusion, the histopathologic differentiation of RHC from ACR after LT had relatively low interobserver and intraobserver agreement rates, and hence showed low reliability. Histopathologic assessment should be used cautiously for the differentiation of RHC from ACR post-LT.

Chronic prenatal exposure to cocaine alters cerebrovascular responses in newborn pigs.

Maternal cocaine abuse may increase the incidence of perinatal asphyxia. In nonexposed asphyxiated neonates, decreased cerebrospinal fluid (CSF) cAMP concentrations are associated with poor neurological outcome. On the other hand, cocaine increases central nervous system (CNS) cAMP. Therefore, we hypothesized that in utero cocaine exposure may increase brain cAMP and thereby preserve cerebrovascular responses to cAMP-dependent stimuli following asphyxia. Pregnant pigs received either cocaine (1 mg/kg, i.v.) twice weekly during the last trimester or normal saline vehicle (sham-control) and were allowed to deliver vaginally at term. Cranial windows were implanted in the newborn pigs within the first week of life and used to collect CSF for cAMP determinations and to assess changes in pial arteriolar diameters (PAD). In the first part of the study, pial arteriolar responses to different vasodilator and vasoconstrictor stimuli were evaluated in piglets prior to asphyxia (n = 20). In newborn pigs exposed to cocaine, cerebrovascular responses to hypercapnia and norepinephrine were significantly exaggerated compared to controls. Then, piglets were randomly selected for the second part of the study that involved prolonged asphyxia (n = 12). In cocaine-exposed but not sham-control piglets, CSF cAMP increased markedly during asphyxia. In the sham piglets, but not the cocaine-exposed piglets, CSF cAMP fell progressively below the baseline during recovery. Cerebrovascular reactivity to cAMP-dependent stimuli (hypercapnia and isoproterenol) was preserved during recovery from asphyxia in the cocaine-exposed piglets but significantly attenuated in the sham controls. We conclude that piglets with chronic prenatal exposure to cocaine show exaggerated cerebrovascular responses to vasogenic stimuli and preserved cAMP-dependent cerebral vasoreactivity following asphyxia.