Chronic stress and illness in children: the role of allostatic load.

OBJECTIVE: Recent studies of stress have highlighted the contributions of chronic psychological and environmental stressors to health and well-being. Children may be especially vulnerable to the negative effects of chronic stressors. Allostasis, the body's ability to adapt and adjust to environmental demands, has been proposed as an explanatory mechanism for the stress-health link, yet empirical evidence is minimal. This study tested the proposition that allostasis may be an underlying physiological mechanism linking chronic stress to poor health outcomes in school-aged children. Specifically, we examined whether allostasis would mediate or moderate the link between chronic stress and health. METHOD: To test the hypothesis that allostasis contributes to the relation between chronic stress and poor health, we examined household density as a chronic environmental stressor, cardiovascular reactivity (CVR) as a marker of allostatic load, and number of school absences due to illness as the health outcome in a sample of 81 boys. RESULTS: Structural equation modeling indicated that the mediating model fit the data well, accounting for 17% of the variance in days ill. CONCLUSIONS: Results provide the first evidence that CVR may mediate the relation between household density and medical illness in children. More generally, these findings support the role of allostasis as an underlying mechanism in the link between chronic stress and health.

Membranous glomerulonephritis associated with testicular seminoma.

Proteinuria, often nephrotic in range, is a recognized paraneoplastic syndrome of solid tumours, with membranous glomerulonephritis (MGN) the most common histopathological lesion seen on renal biopsy. A 56-year-old male was found to have proteinuria on routine medical examination. History, physical and serological evaluation failed to reveal an aetiology and subsequent renal biopsy showed MGN, presumed to be idiopathic. Prednisone therapy was begun but this proteinuria did not resolve (> 1 g 24 h-1). Eleven months later the patient discovered a testicular mass which was found to be a stage I seminoma upon excision and metastatic evaluation. His proteinuria rapidly normalized after orchectomy and regional lymph node radiotherapy. This is the first known case of MGN associated with testicular seminoma.

Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study.

We studied the arterial anatomy and the effect of four-part fractures on the vascularity of the humeral head, using barium sulphate perfusion of 16 cadaver shoulders. The main arterial supply to the humeral head was via the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There were significant intraosseous anastomoses between the arcuate artery and: 1) the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus; 2) metaphyseal vessels; and 3) the vessels of the greater and lesser tuberosities. Simulated four-part fractures prevented the perfusion of the humeral head in most cases. If, however, the head fragment extends distally below the articular surface medially, some perfusion of the head persists by the posteromedial vessels. These vessels are important in the management of comminuted fractures of the proximal humerus.

A quantitative histological study of the vascularity of the rotator cuff tendon.

Previous perfusion studies of the rotator cuff have demonstrated an area of hypovascularity in the distal part of the supraspinatus tendon. This has been implicated in the pathogenesis of its rupture. We performed a quantitative histological analysis of the vascularity of the tendons of supraspinatus and infraspinatus. Vessel number, size and the percentage of the tendon occupied by vessels were measured at 5 mm intervals from the humeral insertions to the muscle bellies. Both tendons were hypovascular in their distal 15 mm. No significant difference was demonstrated between the vascularity of supraspinatus and infraspinatus. We conclude that factors other than vascularity are important in the pathogenesis of supraspinatus rupture.

Do area health education center programs produce primary care specialists? Results of a longitudinal study.

This longitudinal study examined the effect of an urban Area Health Education Center (AHEC) program on choice of primary care as a medical specialty by comparing three groups of medical students. The first group was not exposed to any AHEC clinical training. All other students were variously exposed: one group received AHEC training only in required ambulatory/primary care clerkships, whereas the other group voluntarily took one or more AHEC-sponsored clinical electives. Applying chi-square analysis and the Z-score test for correlated data, no meaningful program effect was found at the end of the fourth year of medical school or seven years after graduation. These results are discussed in the context of program implementation and contemporary medical education in the United States.

Rating journals in health care administration. The perceptions of program chairpersons.

The perceived quality of a journal is often a heavily weighted factor in the appraisal of faculty performance. We developed a listing of 53 prominent journals in the field of health care administration and surveyed the chairpersons of the 52 accredited graduate programs in the United States, Canada, and Puerto Rico, asking each to rate the level of achievement of a faculty member who published in each journal. Using the chi-square goodness-of-fit method for a multinomial experiment, we were able to identify six distinct "tiers" of journals and show a relationship between the subject category of a journal and its tier ranking. The implications of the study findings for faculty members are addressed, followed by a discussion of the data limitations and suggestions for future research.

The influence of medical school clinical experiences on career preferences: a multidimensional perspective.

This study examines the multiple influences of medical school clinical experiences on student career preferences. The analysis of responses to pre-clerkship and post-clerkship questionnaires administered to the 1983 graduating class of a well-established medical school in the Great Lakes region of the United States indicates significant changes in career plans: away from primary care practice towards the surgical specialties; away from office-based practice towards clinical practice in a university medical center; and away from practice in small towns and communities towards locations in larger cities. These changes in the last 2 years of medical school appear to stem from an increased exposure to research and sophisticated medical technology. If allowed to continue, this trend in medical education will contribute further to the clinical specialty and geographic maldistribution problems of medicine in the United States.

Cost differences between hospice and nonhospice care. A comparison of insurer payments and provider charges.

Although it has been postulated that hospice care savings are "biased" when costs are measured in terms of insurer payments instead of provider charges, this claim has not been documented by research. This article examines cost differences between hospice and nonhospice care, first, by analyzing Medicare Part A payments and, second, by studying provider charges for services rendered to a population of 24 cancer patients during their last 24 weeks of life. The exploratory results of the study showed that although the cost savings derived from analyzing provider charges were about double those based on Medicare Part A payments, both approaches to the measurement of cost strongly indicated that hospice home care was less costly than nonhospice care. Further analysis showed that variations in the rates of Medicare reimbursement accounted for 22 to 42% of the differences in the derived cost savings between the two approaches to measuring cost, and that payments to hospitals played a major role in determining this outcome.

A comparative analysis of Medicare home care cost savings for the terminally ill.

Claims histories of 1,148 Medicare beneficiaries who died of cancer were examined to determine if traditional home care, compared to hospice home care and conventional oncological care, achieved substantial cost savings. Using analysis of variance and the test for the difference between percentages, the study indicated that although traditional home care beneficiaries were about one-third more costly during the last 24 weeks of life than either the hospice home care or conventional care patients, there appeared to be some cost savings during the last 4 weeks of life. The analysis clearly showed that the substitution of home care visits for hospital days occurred much more readily in hospice home care than in traditional home care. As a consequence, the cost savings potential of hospice home care was substantially greater. The study did not show a tendency for daily hospital costs to decline among the hospice or traditional home care patients as death approached. Thus, the hypothesis that home care services achieve cost savings by reducing the daily cost of hospital inpatient care was not supported.

Hospice home care cost savings to third-party insurers.

A population-based, retrospective analysis of Medicare Part A and Blue Cross hospital insurance claims data was used to determine whether hospice home care cost savings to third-party insurers are substantial and result from the substitution of less expensive home care visits for more costly hospital inpatient days. The study was carried out by comparing the third-party payments of Cuyahoga County residents who died of cancer and were served by a hospice home care program (n = 152) with the insurance payments of cancer patients who never received hospice home care (n = 1,397). The data strongly supported the research hypothesis. The relative use of hospital days decreased more than 50% and the use of home care visits increased 10-fold when dying patients shifted from conventional care to hospice home care. This change in use represented a relative savings of about 40%, ranging from $1,089 per patient during the last 2 weeks of life to $2,676 per patient during the last 12 weeks of life. These results were not accounted for by group differences in age, type of cancer, or personal preference for home care.

The response of special education students to an activity-centered health curriculum.

The study's purpose was to assess the effectiveness of an activity-centered health education curriculum designed for regular students on the general health beliefs of special education students. As part of an entire school system evaluation, 92 Learning Disability students and 142 Learning Limitation students were randomly assigned to experimental and control groups. All the students were pretested and subsequently posttested using a 28-item questionnaire based on the Health Belief Model. The analysis of covariance indicated that the activity-centered health education program apparently was effective among the Learning Disability students, but was not effective among students with IQ scores of 80 or below.

The potential cost savings of hospice care: a review of the literature.

Virtually every study comparing the costs of hospice and conventional care provided to dying patients has reported substantial savings for hospice care. Yet despite these findings, third-party insurers have not enthusiastically supported this mode of palliative care. To understand why the cost-effectiveness of hospice care is still being questioned, the major findings of nine studies are reviewed in this article. Although the literature shows that hospice costs are much lower than those of hospital care, there is negligible evidence that great savings are achieved by substituting home care visits for hospital days. Third parties tend to view hospice care, therefore, as an "add-on" service.

Evaluation of an activity-centered health curriculum: assessment of cognitive knowledge.

This study was to determine how effective an activity-centered health curriculum was in providing health information to fourth, fifth and sixth-grade students in the Canton City school system. The assessment was facilitated by a posttest-only research design. Ten schools were randomly selected to receive a new health program, as compared to a control group of 10 schools which did not. Results indicated that the experimental students achieved significantly higher posttest cognitive knowledge mean scores than the control students. These findings were sustained for each grade level after adjusting for group differences in reading ability.

Expeditious location of the embedded proximal left anterior descending coronary artery.

Retrograde passage of an intraluminal coronary artery probe to the proximal segment of the anterior descending coronary artery facilitates location of the vessel at operation. No related complications have occurred in 18 patients in whom this maneuver was performed. This method reduces the required dissection time and the hazard involved when aortocoronary bypass to an embedded left anterior descending coronary artery is necessary.