Natural history, treatment, and course of papillary thyroid carcinoma

We have analyzed the course of papillary thyroid carcinoma in 269 patients managed at the University of Chicago, with an average follow-up period of 12 yr from the time of diagnosis. Patients were categorized by clinical class; I, with intrathyroidal disease; II, with cervical nodal metastases; III, with extrathyroidal invasion; and IV, with distant metastases. Half of the patients had a history of thyroid enlargement known, on the average, for over 3 yr. In 15% of patients given thyroid hormone, the mass decreased in size. The peak incidence of cancer was when subjects were between 20-40 yr of age. Tumors averaged 2.4 cm in size; 21.6% had tumor capsule invasion, and 46% of patients had multifocal tumors. Sixty-six percent of the patients had near-total or total thyroidectomy. The overall incidence of postoperative hypoparathyroidism was 8.4%, but the incidence was zero in 83 near-total or total thyroidectomies carried out by 1 surgeon. Twenty-five percent of the patients had continuing or recurrent disease, and 8.2% died from cancer. Deaths occurred largely in patients with class III or IV disease. Cervical lymph nodes were associated with increased recurrences, but not increased deaths. Extrathyroidal invasion carried an increased risk of 5.8-fold for death, and distant metastases increased this risk 47-fold. Age over 45 yr at diagnosis increased the risk of death 32-fold. Tumor size over 3 cm increased the risk of death 5.8-fold. Surgical treatment combining lobectomy plus at least contralateral subtotal thyroidectomy was associated, by Cox proportional hazard analysis, with decreased risk of death in patients with tumors larger than 1 cm and decreased risk of recurrence among all patients, including patients in classes I and II, compared to patients who underwent unilateral thyroid surgery or bilateral subtotal resections. By chi 2 analysis, 131I ablation of residual thyroid tissue after operation was associated with decreased risk of recurrence in tumors larger than 1 cm and decreased risk of death in patients in classes I and II with tumors more than 1 cm in size. The data strongly support the use of more extensive initial surgery in class I and II patients with tumors more than 1 cm in size as well as postoperative radioactive 131I ablation of thyroid remnant tissue.

Changes in muscle morphology, electromyographic activity, and force production characteristics during progressive strength training in young and older men

Effects of a 10-week progressive strength training program composed of a mixture of exercises for increasing muscle mass, maximal peak force, and explosive strength (rapid force production) were examined in 8 young (YM) (29+/-5 yrs) and 10 old (OM) (61+/-4 yrs) men. Electromyographic activity, maximal bilateral isometric peak force, and maximal rate of force development (RFD) of the knee extensors, muscle cross-sectional area (CSA) of the quadriceps femoris (QF), muscle fiber proportion, and fiber areas of types I, IIa, IIb, and IIab of the vastus lateralis were evaluated. Maximal and explosive strength values remained unaltered in both groups during a 3-week control period with no training preceding the strength training. After the 10-week training period, maximal isometric peak force increased from 1311+/-123 N by 15.6% (p <.05) in YM and from 976+/-168 N by 16.5% (p <.01) in OM. The pretraining RFD values of 4049+/-791 N*s(-1) in YM and 2526+/-1197 N*s(-1) in OM remained unaltered. Both groups showed significant increases (p < .05) in the averaged maximum IEMGs of the vastus muscles. The CSA of the QF increased from 90.3+/-7.9 cm2 in YM by 12.2% (p <.05) and from 74.7+/-7.8 cm2 in OM by 8.5% (p <.001). No changes occurred in the muscle fiber distribution of type I during the training, whereas the proportion of subtype IIab increased from 2% to 6% (p < .05) in YM and that of type IIb decreased in both YM from 25% to 16% (p < .01) and in OM from 15% to 6% (p < .05). The mean fiber area of type I increased after the 10-week training in YM (p < .001) and OM (p < .05) as well as that of type IIa in both YM (p < .01) and OM (p < .01). The individual percentage values for type I fibers were inversely correlated with the individual changes recorded during the training in the muscle CSA of the QF (r=-.56, p < .05). The present results suggest that both neural adaptations and the capacity of the skeletal muscle to undergo training-induced hypertrophy even in older people explain the gains observed in maximal force in older men, while rapid force production capacity recorded during the isometric knee extension action remained unaltered during the present mixed strength training program.

Effects of heavy-resistance training on hormonal response patterns in younger vs. older men

To examine the adaptations of the endocrine system to heavy-resistance training in younger vs. older men, two groups of men (30 and 62 yr old) participated in a 10-wk periodized strength-power training program. Blood was obtained before, immediately after, and 5, 15, and 30 min after exercise at rest before and after training and at rest at -3, 0, 6, and 10 wk for analysis of total testosterone, free testosterone, cortisol, growth hormone, lactate, and ACTH analysis. Resting values for insulin-like growth factor (IGF)-I and IGF-binding protein-3 were determined before and after training. A heavy-resistance exercise test was used to evaluate the exercise-induced responses (4 sets of 10-repetition maximum squats with 90 s of rest between sets). Squat strength and thigh muscle cross-sectional area increased for both groups. The younger group demonstrated higher total and free testosterone and IGF-I than the older men, training-induced increases in free testosterone at rest and with exercise, and increases in resting IGF-binding protein-3. With training the older group demonstrated a significant increase in total testosterone in response to exercise stress along with significant decreases in resting cortisol. These data indicate that older men do respond with an enhanced hormonal profile in the early phase of a resistance training program, but the response is different from that of younger men.

Health-related quality of life in chronic liver disease: the impact of type and severity of disease

OBJECTIVE

The type and severity of chronic liver disease may have different effects on health-related quality of life (HRQL). The aim of our study was to determine whether HRQL in patients with chronic liver disease differs by type and severity of disease and to identify which clinical and physiological factors affect this impairment.

METHODS

In this study, HRQL was measured with a generic (Short Form 36) and a liver disease-specific (Chronic Liver Disease Questionnaire) questionnaire. Clinical, demographic, and laboratory data were collected at office visits. Patient's HRQL scores were compared with the published norms and to the chronically ill populations. A total of 353 patients (mean age 50 yr, 51% men) with chronic liver disease, either viral disease (hepatitis B and C), cholestatic disease (primary biliary cirrhosis or primary sclerosing cholangitis), or hepatocellular disease were enrolled in the study.

RESULTS

In general, HRQL in patients with chronic liver disease was lower than the normal population and was similar to that of patients with chronic obstructive pulmonary disease or congestive heart failure. In cirrhotic patients, some dimensions of HRQL were less impaired in patients with cholestatic disease than in those with hepatocellular diseases. More severe disease (higher Child's class) was associated with a lower Chronic Liver Disease Questionnaire score and the Short Form 36's physical component summary scores. Older age had a weak negative association with the physical aspects of HRQL.

CONCLUSIONS

We conclude that chronic liver disease substantially reduces HRQL, and this impact does not differ markedly by type of disease. Older age and measures of disease severity were associated with poorer HRQL.

2500 years of European climate variability and human susceptibility

Climate variations influenced the agricultural productivity, health risk, and conflict level of preindustrial societies. Discrimination between environmental and anthropogenic impacts on past civilizations, however, remains difficult because of the paucity of high-resolution paleoclimatic evidence. We present tree ring-based reconstructions of central European summer precipitation and temperature variability over the past 2500 years. Recent warming is unprecedented, but modern hydroclimatic variations may have at times been exceeded in magnitude and duration. Wet and warm summers occurred during periods of Roman and medieval prosperity. Increased climate variability from ~250 to 600 C.E. coincided with the demise of the western Roman Empire and the turmoil of the Migration Period. Such historical data may provide a basis for counteracting the recent political and fiscal reluctance to mitigate projected climate change.

Assessment of utilities and health-related quality of life in patients with chronic liver disease

OBJECTIVES

Quantitative measures of the value patients place on the state of their health is crucial to understanding their experience, and to calculate quality-adjusted years of life for economic analyses. Patients' values in chronic liver disease remain unexplored, although experts' estimates of utilities have been examined. Our study tests the validity of a widely used utility measure in chronic liver disease and, if valid, establishes the decrement in health-related quality associated with chronic liver disease.

METHODS

A total of 120 patients with chronic liver disease participated in the study (age 50 +/- 10 yr; men 53%; cirrhosis 51%, chronic viral hepatitis 51%, and chronic cholestatic liver disease 30%). All patients completed three instruments: Health Utility Index Mark 2 (scores 0-1), Short Form-36 (scale scores 0-100), and a disease-specific health-related quality of life instrument (Chronic Liver Disease Questionnaire; scores 1-7).

RESULTS

We found a moderate to strong correlation between scores on the three measures and that impairment worsened as the severity of disease worsened. Patients without cirrhosis and those with Child's A cirrhosis showed substantial decrement in utilities (0.82 and 0.83, respectively) in the range of patients surviving brain tumor. Those with Child's B and C showed a greater decrement (0.67 and 0.56) that was in the range experienced by patients who survive a stroke (0.67). Utilities assessed by Health Utility Index Mark 2 differed substantially from estimates by "expert."

CONCLUSIONS

We conclude that utilities should be based on patient reports and that the data from this study can inform economic analyses in studies of patients with chronic liver disease.

Profiling of sputum inflammatory mediators in asthma and chronic obstructive pulmonary disease

Background

Asthma and chronic obstructive pulmonary disease (COPD) display features of overlap in airway physiology and airway inflammation. Whether inflammatory phenotypes in airway disease describe similar mediator expression is unknown.

Objectives

To explore the relationship of airway inflammation and cytokine and chemokine expression in asthma and COPD.

Methods

Subjects with asthma and COPD (n = 54 and n = 49) were studied. Clinical characteristics and sputum were collected at entry into the study. A 2-step sputum processing method was performed for supernatant and cytospin preparation. Meso Scale Discovery and Luminex platforms were used to measure cytokines, chemokines and matrix metalloproteinase levels.

Results

Analytes sensitive to dithiothreitol (DTT) that had increased recovery in the 2-step sputum process were IL-1β, 4, 5, 10, 13, IFN-γ, TNFRI, GM-CSF, CCL2, 3, 4, 5, 13 and 17. There was a differential expression in IL-8, TNFRI and TNFRII between asthma and COPD [mean fold difference (95% CI): IL-8, 2.6 (1.3–5.4), p = 0.01; TNFRI, 2.1 (1.3–5.4), p = 0.03; TNFRII, 2.6 (1.2–5.6), p = 0.02]. In neutrophilic and eosinophilic airway inflammation, TNFα, TNFRI, TNFRII, IL-6, IL-8 and IL-5 could differentiate between these phenotypes. However, these phenotypes were unrelated to the diagnosis of asthma or COPD.

Conclusion

Recovery of sputum mediators sensitive to DTT can be improved using the described sputum processing technique. Within airway inflammatory sub-phenotypes there is a differential pattern of mediator expression that is independent of disease. Whether these inflammatory phenotypes in asthma and COPD confer distinct pathogeneses, therapeutic responses and clinical phenotypes needs to be further evaluated.

Cisplatinum and bleomycin for advanced or recurrent squamous cell carcinoma of the head and neck: a randomised factorial phase III controlled trial

A phase III 2 X 2 factorial trial of cisplatinum and bleomycin in 116 patients with recurrent or advanced squamous cell carcinoma of the head and neck is reported. Thirty percent of patients proved to be unfit for chemotherapy, and of those treated progression of tumour was the commonest "response". However, 25% of patients achieved a partial or complete response, with no significant difference in response rates between the treated arms. The median number of courses received was 1 (range 0-6) and the commonest causes for discontinuation of treatment were renal toxicity and death. Bleomycin reduced survival, but not significantly so, whereas cisplatinum prolonged median survival significantly by 10 weeks. Significant predictors of survival, in addition to treatment by cisplatinum, were age, performance status, N status, number of courses and response of the tumor.

Long-term follow-up study of compensated low-dose 131I therapy for Graves' disease

We treated 187 patients who had Graves' disease with low-dose radioactive iodide (131I), using a protocol that included a compensation for thyroid size. The incidence of early hypothyroidism (12 per cent) was acceptably low in the first year after 131I treatment, but we found a cumulative high incidence (up to 76 per cent) at the end of the 11th year. In contrast, the incidence of permanent hypothyroidism was relatively stable in 166 surgically treated patients, increasing from 19 to 27 per cent at the end of 11 years. Among 122 medically treated patients, only 40 per cent entered remission, and hypothyroidism developed in 2 per cent during the same period of follow-up. The long-term incidence of hypothyroidism in our patients treated with low-dose 131I therapy was much higher than that found in earlier studies using a comparable dose. Our study suggests that it will be difficult to modify therapy with 131I alone to produce both early control of thyrotoxicosis and a low incidence of hypothyroidism.

A 37 X 10(3) molecular weight plasmid-encoded protein is required for replication and copy number control in the plasmid pSC101 and its temperature-sensitive derivative pHS1

Nucleotide sequences were determined for a region essential for autonomous replication and partitioning of pSC101, a plasmid whose replication is dependent on the Escherichia coli dnaA gene product. The essential replication region contains one long coding sequence, rep101 , for a protein composed of 316 amino acids, and a polypeptide approximately 37 X 10(3) Mr in size was identified as the rep101 gene product. rep101 is preceded by two inverted repeat sequences, three directly repeated sequences and a region of high A + T content containing a sequence similar to the E. coli oriC consensus sequence. Because the lesions in seven replication-deficient insertion mutants, four mutants with increased copy number and one temperature-sensitive replication mutant occur within rep101 , the rep101 gene product must control pSC101 replication and copy number. par, a region adjacent to the replication region, which functions in stable plasmid inheritance, contains several inverted repeat sequences.

A High-Coverage Yersinia pestis Genome from a Sixth-Century Justinianic Plague Victim

The Justinianic Plague, which started in the sixth century and lasted to the mid eighth century, is thought to be the first of three historically documented plague pandemics causing massive casualties. Historical accounts and molecular data suggest the bacterium Yersinia pestis as its etiological agent. Here we present a new high-coverage (17.9-fold) Y. pestis genome obtained from a sixth-century skeleton recovered from a southern German burial site close to Munich. The reconstructed genome enabled the detection of 30 unique substitutions as well as structural differences that have not been previously described. We report indels affecting a lacl family transcription regulator gene as well as nonsynonymous substitutions in the nrdE, fadJ, and pcp genes, that have been suggested as plague virulence determinants or have been shown to be upregulated in different models of plague infection. In addition, we identify 19 false positive substitutions in a previously published lower-coverage Y. pestis genome from another archaeological site of the same time period and geographical region that is otherwise genetically identical to the high-coverage genome sequence reported here, suggesting low-genetic diversity of the plague during the sixth century in rural southern Germany.

Acute hormonal responses to heavy resistance exercise in younger and older men

The purpose of this investigation was to examine the acute responses of several hormones [total and free testosterone (TT and FT, respectively), adrenocorticotropic hormone (ACTH), cortisol (C), growth hormone (GH), and insulin (INS)] to a single bout of heavy resistance exercise (HRE). Eight younger [30-year (30y) group] and nine older [62-year (62y) group] men matched for general physical characteristics and activity levels performed four sets of ten repetitions maximum (RM) squats with 90 s rest between sets. Blood samples were obtained from each subject via an indwelling cannula with a saline lock pre-exercise, immediately post-exercise (IP), and 5, 15 and 30 min post-exercise. Levels of TT, FT, ACTH, C and lactate significantly increased after HRE for both groups. Pre-HRE pairwise differences between groups were noted only for FT, while post-HRE pairwise differences were found for TT, FT, GH, glucose and lactate. Area under the curve analysis showed that the 30y group had a significantly higher magnitude of increase over the entire recovery period (IP, 5, 15, and 30 min post-exercise) for TT, FT, ACTH and GH. Few changes occurred in the INS response with the only change being that the 62y group demonstrated a decrease IP. Lactate remained elevated at 30 min post-HRE. This investigation demonstrates that age-related differences occur in the endocrine response to HRE, and the most striking changes appear evident in the FT response to HRE in physically active young and older men.

Relationship between birthweight and blood pressure in childhood

Studies have shown an inverse relationship between birthweight and blood pressure in later life. The objective of this study is to analyze the relationship between birthweight and blood pressure in childhood in a North American-based population. Data on 2,958 births with follow-up at 7 years of age from the Providence, RI, cohort of the Collaborative Perinatal Project of the National Institute of Neurological Diseases and Stroke were retrospectively analyzed using univariate and multivariate analytic methods. Bivariate analysis of the total cohort showed a direct relationship between follow-up weight at age 7 years and birthweight (r = 0.24; P < 0.001) and follow-up weight with systolic (SBP) and diastolic blood pressure (DBP; r = 0.33; P < 0.001 and r = 0.22; P < 0.001, respectively). On multivariate analysis, follow-up weight and height were the strongest predictors of SBP and DBP. There was also a significant inverse relationship between birthweight and SBP. A cohort of term infants (n = 2,561) was subdivided into birthweight-for-gestational-age groupings to further evaluate the effects of birthweight on blood pressure. Small-for-gestational-age (SGA) infants were markedly smaller at age 7 years than those large-for-gestational-age (LGA; 21 +/- 4 kg v 26 +/- 4 kg; P < 0.01). Despite the direct association between follow-up weight and blood pressure, the mean blood pressure did not differ between SGA (103/58 mm Hg) and LGA patients (103/59 mm Hg). To assess whether birthweight was an independent predictor of blood pressure, blood pressures were predicted using linear regression equations. For every 1-kg decrease in birthweight in term infants, SBP at 7 years increased by 1.3 mm Hg and DBP by 0.6 mm Hg. In conclusion, controlling for weight and height in term infants at 7 years of age has an inverse linear effect on blood pressure. This suggests that birthweight in relation to gestation may be a contributor to the multifactorial cause of essential hypertension.

Impact of liver transplantation on health-related quality of life

This study is designed to measure the impact of orthotopic liver transplantation (OLT) on patients' health-related quality of life. Two types of health-related quality-of-life questionnaires were administered at baseline and after OLT: generic (Medical Outcomes Study Short Form 36) and liver specific (Chronic Liver Disease Questionnaire). We also recorded clinical, demographic, and laboratory data. Pre-OLT scores of liver transplant candidates were compared with those of the general population and patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Thirty-seven liver transplant candidates were evaluated: 25 men and 12 women; age, 50.2 +/- 12 years; Child's class A, 3 patients; class B, 30 patients; class C, 4 patients; and galactose elimination capacity, 277 +/- 81. Health-related quality-of-life scores for patients awaiting liver transplants were significantly lower than those for patients with COPD and CHF and those in the general population. Sex and cause of liver disease did not affect the scores. There was a weak but significant inverse correlation between some aspects of health-related quality of life and both age (r = -0.31 to -0.34) and worsening of the Child-Pugh score (r = -0.32 to -0.43). All measured aspects of health-related quality of life significantly improved after OLT, and mental health scores were indistinguishable from the population norms. Similar improvements were evident in physical and disease-specific aspects of health-related quality of life, but some residual dysfunction persisted.

Life after Tracheostomy: Patient and Family Perspectives on Teaching, Transitions, and Multidisciplinary Teams

OBJECTIVE

To report patient/family experiences and outcomes after tracheostomy

STUDY DESIGN

International survey of patients and families with tracheostomy.

SETTING

Collaboration of the Patient Safety and Quality Improvement Committee of the American Academy of Otolaryngology-Head and Neck Surgery and the Global Tracheostomy Collaborative.

METHODS

A 50-item survey was developed with multistakeholder collaboration. The survey was disseminated via international social networks used by patients with a tracheostomy and their families. Qualitative and quantitative data were analyzed.

RESULTS

Of 220 respondents, 90% cared for a pediatric patient with a tracheostomy. Only 48% of respondents felt "very prepared" at time of discharge, and 11% did not receive emergency preparedness training prior to discharge. Home nursing needs were inadequately met in 17% of families, with resulting difficulties shortly after discharge; 14% sought emergent care within 1 week of discharge. Nearly half of respondents indicated a desire to have met with a patient with a tracheostomy prior to surgery but were not offered that opportunity. Fragmented care or limited teamwork was reported by 32% of respondents, whereas tracheotomy care was described as "integrated" or "maximally integrated" for 67%.

CONCLUSION

While many families report satisfaction with tracheostomy care, opportunities remain for improving care. This study highlights the importance of teaching, teamwork, and smoothing transition from the hospital. Potential quality improvement areas include standardizing tracheostomy teaching for routine and emergency needs and optimizing postdischarge support and coordination. Prior to surgery, connecting families to people with a tracheostomy may also be beneficial.

Randomized, controlled trial of insulin for acute poststroke hyperglycemia

OBJECTIVE

Poststroke hyperglycemia is common and is associated with increased risk of death and dependence, but appropriate management remains uncertain. Glucose potassium insulin (GKI) infusion did not benefit patients with moderate poststroke hyperglycemia in a recent trial. Using magnetic resonance imaging (MRI), previous studies identified a relationship between recruitment of ischemic tissue to the final infarct and hyperglycemia, possibly mediated by brain lactic acidosis.

METHODS

We undertook a randomized, placebo-controlled trial of GKI infusion in patients with blood glucose >126mg/dl (7mmol/l) within 24 hours of ischemic stroke. The primary endpoint was infarct growth on MRI between baseline and day 7. Brain lactate concentrations were measured with magnetic resonance spectroscopy.

RESULTS

Forty patients were randomized, 15 to saline and 25 to GKI infusions of different durations. Capillary blood glucose concentrations were lowered significantly from 6 to 12 hours after GKI initiation. There was no significant difference on any measure of infarct growth between the GKI and saline groups. In a secondary analysis, GKI was associated with significantly greater infarct growth in patients with complete intracranial vessel occlusion compared with controls (p = 0.011 for group-vessel status interaction). Brain lactate levels increased in control subjects, but were significantly lower with GKI infusion. Predominantly asymptomatic hypoglycemia occurred in 76% of GKI-treated subjects.

INTERPRETATION

GKI infusion within 24 hours of stroke lowered blood glucose and attenuated an increase in brain lactate, but did not affect cerebral infarct growth. Exploratory analysis found that GKI infusion was associated with greater infarct growth in patients with persistent arterial occlusion, and with a high incidence of asymptomatic hypoglycemia.

Methods for robust in vivo strain estimation in the carotid artery

A hierarchical block-matching motion tracking algorithm for strain imaging is presented. Displacements are estimated with improved robustness and precision by utilizing a Bayesian regularization algorithm and an unbiased subsample interpolation technique. A modified least-squares strain estimator is proposed to estimate strain images from a noisy displacement input while addressing the motion discontinuity at the wall-lumen boundary. Methods to track deformation over the cardiac cycle incorporate a dynamic frame skip criterion to process data frames with sufficient deformation to produce high signal-to-noise displacement and strain images. Algorithms to accumulate displacement and/or strain on particles in a region of interest over the cardiac cycle are described. New methods to visualize and characterize the deformation measured with the full 2D strain tensor are presented. Initial results from patients imaged prior to carotid endarterectomy suggest that strain imaging detects conditions that are traditionally considered high risk including soft plaque composition, unstable morphology, abnormal hemodynamics and shear of plaque against tethering tissue can be exacerbated by neoangiogenesis. For example, a maximum absolute principal strain exceeding 0.2 is observed near calcified regions adjacent to turbulent flow, protrusion of the plaque into the arterial lumen and regions of low echogenicity associated with soft plaques. Non-invasive carotid strain imaging is therefore a potentially useful tool for detecting unstable carotid plaque.

Mortality and morbidity in infants with intrauterine growth retardation

This report is based on an analysis of the experience with all births in several urban and rural areas of the United States. All infants whose birth weight was in the lowest quartile for their week of gestation were designated as small for gestational age regardless of their birth weight or length of gestation; other infants were considered appropriate for gestation age. We interpret the data to indicate that appropriate-for-gestational age and small-for-gestational age infants, all of low birth weight, differ in the nature of their risk for adverse outcome as determined by an assessment at one year of age, although both are at approximately equal risk of adverse outcome overall. In each weight group, the total proportion of infants who either died before one year of age or were handicapped at one year of age was similar for small-for-gestational age and appropriate-for-gestational age infants, but appropriate-for-gestational age infants were at greater risk of neonatal death and small-for-gestational age infants were at greater risk of problems manifested during the first year of life or at one year of age. As the findings are based on data obtained from entire populations (rather than from infants born in particular hospitals), they are likely to be generalizable.

The Protective Effects of Supportive Parenting on the Relationship Between Adolescent Poverty and Resting-State Functional Brain Connectivity During Adulthood

Children growing up in poverty are vulnerable to negative changes in the developing brain; however, these outcomes vary widely. We tested the hypothesis that receipt of supportive parenting would offset the association between living in poverty during adolescence and the connectivity of neural networks that support cognition and emotion regulation during young adulthood. In a sample of African American youths (N = 119) living in the rural South, poverty status and receipt of supportive parenting were assessed when youths were 11 to 13 and 16 to 18 years old. At age 25, resting-state functional connectivity of the central-executive and emotion-regulation neural networks was assessed using functional MRI. The results revealed that more years spent living in poverty presaged less connectivity in both neural networks among young adults who received low levels of supportive parenting but not among those who received high levels of such parenting.

Which children with febrile seizures need lumbar puncture? A decision analysis approach

Whether all children brought to the emergency room with a first seizure and fever require lumbar puncture (LP) remains controversial. We reviewed the emergency room records of 241 children aged 6 months to 6 years who had this clinical picture. Five history and physical examination items discriminated between children with and without meningitis: a physician visit within 48 hours before the seizure; the occurrence of convulsions on arrival at the emergency room; a focal seizure; suspicious findings on physical and/or neurologic examination. Used in combination, these items (risk factors) identified all children with meningitis but would have spared 62% of children without meningitis the need for LP. In a decision analysis framework, they were as sensitive but more specific than LP in detecting children with meningitis. Most important, their negative predictive value was 100%.