Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy

BACKGROUND

Psychological and pharmacological treatments have been shown to reduce rates of transition to psychosis in Ultra High Risk (UHR) young people. However, social functioning deficits have been unresponsive to current treatments.

AIMS

The study aims were to: i) describe the theoretical basis and therapeutic targets of a novel intervention targeting social functioning in UHR young people; and ii) examine its acceptability, safety and preliminary effect on social functioning.

METHODS

An international, multidisciplinary team developed a new intervention (MOMENTUM) to improve social functioning in UHR young people. MOMENTUM blends two novel approaches to social recovery: strengths and mindfulness-based intervention embedded within a social media environment, and application of the self-determination theory of motivation. The acceptability and safety of MOMENTUM were tested through a 2-month pilot study with 14 UHR participants.

RESULTS

System usage was high, with over 70% of users being actively engaged over the trial. All participants reported a positive experience using MOMENTUM, considered it safe and would recommend it to others. 93% reported it to be helpful. There were large, reliable improvements in social functioning (d = 1.83, p < 0.001) and subjective wellbeing (d = 0.75, p = 0.03) at follow-up. There were significant increases in the mechanisms targeted by the intervention including strengths usage (d = 0.70, p = 0.03), mindfulness skills (d = 0.66, p = 0.04) and components of social support. Social functioning improvement was significantly correlated with indicators of system usage.

CONCLUSION

MOMENTUM is engaging and safe. MOMENTUM appeared to engage the hypothesized mechanisms and showed promise as a new avenue to improve social functioning in UHR young people.

Abstract P4-19-01: Attitudes of medical oncologists towards research biopsies

Background:

There is increasing interest in studying tissue from patients (pts) with metastatic breast cancer (MBC). Historically, limited tissue has been available. Possible barriers to research biopsies (bx) include pt and provider opinions; the contribution of each factor is unknown.

Methods:

309 academic breast medical oncologists (MOs) identified from the websites of each of the National Cancer Institute - designated cancer centers were invited to complete either a self-administered paper or online survey. Eligible MOs (MOs who saw breast cancer pts and who saw pts 4 hours/week.) were asked to predict what proportion of their pts with MBC would consent to additional bx (ABs, additional bx performed with a clinically indicated bx) or research purposes only bx(RPOBs, research bx performed as a standalone procedure). They were also asked about their comfort levels in asking pts with MBC to consider participating in ABs or RPOBs for various organs. Median values are reported. Two-sided Fisher's exact test was used to compare categorical variables using a a level of .05.

Results:

191 (101F,85M, 5 unknown) eligible MOs completed the survey. 29 MOs were ineligible (response rate = 191/280,68%). Median age was 50 (Range 33-80). Median years of oncology experience was 15 (Range 1-45). MOs predicted that 90%, 75%, 70% and 50%, of their pts would definitely/probably consider ABs of blood, skin, breast, or liver respectively. MOs predicted that 90%, 60%, 33%, and 20% of their pts would definitely/probably consider RPOBs of blood, skin, breast, or liver. 98% (95% CI 96%-100%), 96% (95% CI 92%-98%), 93% (95% CI 88%-96%) and 70% (95% CI 63%-77%) of MOs were very/somewhat comfortable asking pts for an AB of blood, skin, breast and liver respectively. 98% (95% CI 95%-99%), 93% (95% CI 89%-96%), 78% (95% CI 72%-84%) and 50% (95% CI 43%-58%) of MOs were very/somewhat comfortable asking pts to participate in a RPOB of blood, skin, breast and liver respectively.

No demographic characteristics (eg. sex, age) were associated with MOs’ comfort levels of asking pts to have an AB of blood, skin and breast.

Factors associated with increased comfort discussing an AB of the liver were: age &lt; 50 years (p = 0.01), in practice for &lt; 15 years (p = 0.01), ≥ 1 pt enrolled on clinical trials per month (p = 0.02), or having pts who had undergone bx for research in prior 3 months (p&lt;0.01).

MOs with ≥ 4 patients enrolled on clinical trials/month or whose pts had undergone research bx in the past 3 months were more likely to feel comfortable asking pts to have a RPOB of the breast (p&lt;0.01; p&lt;0.01) or liver (p = 0.03; p&lt;0.01).

The 3 most common reasons why MOs were reluctant to refer pts for participation in an AB include risk of a bx procedure (n = 128, 67%), pain/discomfort of a bx (n = 125, 65%), and logistical barriers (n = 42, 22%). These reasons are similar for RPOB; risk of a bx procedure, (n = 137, 72%), pain/discomfort of a bx (n = 134, 70%), and inconvenience to pt (time involved, travel, etc) (n = 58, 30%).

Conclusions:

Many MOs predict that the majority of their MBC pts will consider ABs of various organs. However, this decreases with RPOBs, particularly as the procedure becomes more invasive. More research is needed to understand factors that may influence MOs’ comfort levels asking pts to participate in such studies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-19-01.

Internet-based interventions for psychosis: a sneak-peek into the future

The Internet and mobile technologies are becoming ubiquitous. However, the potential of these technologies to support people with psychosis has been unexplored and the development of innovative e-based interventions is overdue. Research suggests the acceptability and effectiveness of such interventions in psychosis. Internet-based technologies have the potential to transform psychosis treatment by enhancing the accessibility of evidence-based interventions, fostering engagement with mental health services, and maintaining treatment benefits over the long term. This article reviews the current evidence on Internet-based interventions for psychosis, including potential benefits, risks, and future challenges. Recommendations are proposed for developing future online interventions for psychosis.

Computerized Evaluation of Mammographic Lesions:What Diagnostic Role Does the Shape of the Individual Microcalcifications Play Compared with the Geometry of the Cluster?

OBJECTIVE

The objective of this study was to compare the diagnostic role of features reflecting the geometry of clusters with features reflecting the shape of the individual microcalcification in a mammographic computer-aided diagnosis system.

MATERIALS AND METHODS

Three hundred twenty-four cases of clustered microcalcifications with biopsy-proven results were digitized at 42-microm resolution and analyzed on a computerized system. The shape factor and number of neighbors were computed for each microcalcification, and the eccentricity of the cluster was computed as well. The shape factor is related to the individual microcalcification; the average number of neighbors and the cluster eccentricity reflect the cluster geometry. Stepwise discriminant analysis was used to evaluate the contribution of the extracted features in predicting malignancy. The performance of a classifier based on the features selected by stepwise discriminant analysis was evaluated by receiver operating characteristic (ROC) analysis.

RESULTS

To obtain the best discrimination model, we used stepwise discriminant analysis to select the average number of neighbors and the shape of the individual microcalcification, but excluded cluster eccentricity. A classification scheme assigned the average number of neighbors a weighting factor, which was 1.49 times greater than that assigned to the shape factor of the individual microcalcification. A scheme based only on these two features yielded an ROC curve with an area under the curve (A(z)) of 0.87, indicating a positive predictive value of 61% for 98% sensitivity.

CONCLUSION

Computerized analysis permitted calculations reflecting the shape of individual microcalcification and the geometry of clusters of microcalcifications. For the computerized classification scheme studied, the cluster geometry was more effective in differentiating benign from malignant clusters than was the shape of individual microcalcification.

Ultrasound-guided thrombin injection for the treatment of iatrogenic pseudoaneurysm of the femoral artery

BACKGROUND

Pseudoaneurysm occurring after catheterization of the femoral artery is associated with significant morbidity. Percutaneous ultrasound-guided thrombin injection has recently emerged as a potential first-line therapy.

OBJECTIVES

To evaluate the efficacy of this treatment in eight patients with iatrogenic femoral artery pseudoaneurysm.

METHODS

After attempted treatment with external compression had failed, eight patients with iatrogenic femoral artery pseudoaneurysm were treated with thrombin injection. Treatment performed between 2 and 9 days following arterial puncture. The study group comprised seven males and one female ranging in age from 23 to 89 years (median 70). Seven had undergone cardiac catheterization with or without intervention, and five were receiving antiplatelet and/or anticoagulant drugs. Arterial pseudoaneurysm resulted from femoral vein catheterization in one patient. Using a sterile technique and real-time Doppler ultrasound guidance, a dilute solution of bovine thrombin (average dose 250 units, range 100-600), was slowly injected directly into the pseudoaneurysm until cessation of flow was seen. Patients were allowed to walk within 2 hours of the procedure and were followed up clinically and by color Doppler ultrasound during the admission.

RESULTS

Cardiac catheterization had been inadvertently performed via the superficial or profunda femoris arteries in four of the eight patients. Thrombin injection was initially successful in all eight patients without complication. Thrombosis occurred immediately in every case. Early recanalization of pseudoaneurysm occurred in one patient despite repeat thrombin injection and attempted ultrasound-guided compression. He eventually required surgical repair. The final success rate was 87.5% (7/8).

CONCLUSION

Faulty puncture technique is an important risk factor for the development of post-catheterization femoral artery pseudoaneurysm. Ultrasound-guided thrombin injection is a safe, rapid, well-tolerated, inexpensive and successful therapy. If initial external compression with a sandbag fails to result in thrombosis of the pseudoaneurysm then thrombin injection should be considered as first-line therapy. If unsuccessful, it does not preclude the use of alternative treatment modalities. Further study is necessary to assess the long-term effects of thrombin injection.

Optimizing parameters for computer-aided diagnosis of microcalcifications at mammography

RATIONALE AND OBJECTIVES

The purpose of this study was to optimize selection of the mammographic features most useful in discriminating benign from malignant clustered microcalcifications.

MATERIALS AND METHODS

The computer-aided diagnosis (CAD) system automatically extracted from digitized mammograms 13 quantitative features characterizing microcalcification clusters. Archival cases (n = 134; patient age range, 31-77 years; mean age, 56.8 years) with known histopathologic results (79 malignant, 55 benign) were selected. Three radiologists at three facilities independently analyzed the microcalcifications by using the CAD system. Stepwise discriminant analysis selected the features best discriminating benign from malignant microcalcifications. A classification scheme was constructed on the basis of these optimized features, and its performance was evaluated by using receiver operating characteristic (ROC) analysis.

RESULTS

Six of the 13 variables extracted by the CAD system were selected by stepwise determinant analysis for generating the classification scheme, which yielded an ROC curve with an area (Az) of 0.98, specificity of 83.64%, positive predictive value of 89.53%, and accuracy of 91.79% for 98% sensitivity. When patient age was an additional variable, the scheme's performance improved, but this was not statistically significant (Az = 0.98). The ROC curve of the classifier (without age as an additional variable) yielded a high Az of 0.96 for patients younger than 50 years and an even higher (P < .02) Az of 0.99 for those 50 years or older.

CONCLUSION

Stepwise discriminant analysis optimized performance of a classification scheme for microcalcifications by selecting six optimized features. Scheme performance was significantly (P < .02) higher for women 50 years or older, but the addition of patient age as a variable did not produce a statistically significant increase in performance.

Quantitative characterization of mass lesions on digitized mammograms for computer-assisted diagnosis

RATIONALE AND OBJECTIVES

To investigate features for discriminating benign from malignant mammographic findings by using computer-aided diagnosis (CAD) and to test the accuracy of CAD interpretations of mass lesions.

METHODS

Fifty-five sequential, mammographically detected mass lesions, referred for biopsy, were digitized for computerized reevaluation with a CAD system. Quantitative features that characterize spiculation were automatically extracted by the CAD system. Data generated by 271 known retrospective cases were used to set reference values indicating the range for malignant and benign lesions. After conventional interpretation of the 55 prospective cases, they were evaluated a second time by the radiologist using the extracted features and the reference ranges. In addition, a pattern-recognition scheme based on the extracted features was used to classify the prospective cases. Accuracy of interpretation with and without the CAD system was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Sensitivity of the CAD diagnosis for the prospective cases improved from 92% to 100%. Specificity improved significantly from 26.7% to 66.7%. This was accompanied by a significant increase in the accuracy of diagnosis from 56.4% to 81.8% and in the positive predictive value from 51.1% to 71.4%. The Az for the CAD ROC curve significantly increased from 0.73 to 0.90. The performance of the classification scheme was slightly lower than that of the radiologists' interpretation with the CAD system.

CONCLUSIONS

Use of the CAD system significantly improved the accuracy of diagnosis. The findings suggest that the classification scheme may improve the radiologist's ability to differentiate benign from malignant mass lesions in the interpretation of mammograms.

Results of employee involvement in planning and implementing the Treatwell 5-a-Day work-site study

When work-site health promotion programs incorporate theories of community organization, it is likely that employee ownership and participation are enhanced. This article reports quantitative indicators of involvement of Employee Advisory Board (EAB) members in the Treatwell 5-a-Day work-site study and examines relationships between EAB member time spent on project activities and work-site size, with indicators of the extent of implementation and variables associated with behavior change and work-site support. The results reported here indicate that a greater number of EAB member hours spent on program activities was associated with a greater number of events implemented. Smaller work-site size was associated with greater employee awareness of the program and greater participation in project activities as reported on the employee survey. These results suggest that the number of hours employee representatives devote to project activities might be an important consideration in planning employee involvement in work-site health promotion programming.

Improved mammographic interpretation of masses using computer-aided diagnosis

The aim of this study was to evaluate the effectiveness of computerized image enhancement, to investigate criteria for discriminating benign from malignant mammographic findings by computer-aided diagnosis (CAD), and to test the role of quantitative analysis in improving the accuracy of interpretation of mass lesions. Forty sequential mammographically detected mass lesions referred for biopsy were digitized at high resolution for computerized evaluation. A prototype CAD system which included image enhancement algorithms was used for a better visualization of the lesions. Quantitative features which characterize the spiculation were automatically extracted by the CAD system for a user-defined region of interest (ROI). Reference ranges for malignant and benign cases were acquired from data generated by 214 known retrospective cases. The extracted parameters together with the reference ranges were presented to the radiologist for the analysis of 40 prospective cases. A pattern recognition scheme based on discriminant analysis was trained on the 214 retrospective cases, and applied to the prospective cases. Accuracy of interpretation with and without the CAD system, as well as the performance of the pattern recognition scheme, were analyzed using receiver operating characteristics (ROC) curves. A significant difference (p < 0.005) was found between features extracted by the CAD system for benign and malignant cases. Specificity of the CAD-assisted diagnosis improved significantly (p < 0.02) from 14 % for the conventional assessment to 50 %, and the positive predictive value increased from 0.47 to 0.62 (p < 0.04). The area under the ROC curve (A(z)) increased significantly (p < 0. 001) from 0.66 for the conventional assessment to 0.81 for the CAD-assisted analysis. The A(z) for the results of the pattern recognition scheme was higher (0.95). The results indicate that there is an improved accuracy of diagnosis with the use of the mammographic CAD system above that of the unassisted radiologist. Our findings suggest that objective quantitative features extracted from digitized mammographic findings may help in differentiating between benign and malignant masses, and can assist the radiologist in the interpretation of mass lesions.

Process tracking results from the Treatwell 5-a-Day Worksite Study

PURPOSE

To report findings from Treatwell 5-a-Day process tracking.

DESIGN

Worksites were randomly assigned to a minimal intervention control, worksite-only condition, or worksite-plus-family condition.

SETTING

Twenty-two small community health centers in Massachusetts.

SUBJECTS

Employees of the community health centers.

INTERVENTION

Both intervention conditions included the formation of employee advisory boards; activities such as nutrition discussions and taste tests targeting individual behavior change; and point-of-purchase labeling as an environmental strategy. Worksite-plus-family sites incorporated activities such as family contests, campaigns, and picnics.

MEASURES

Documentation of the number and type of activities for extent of implementation; number of participants in activities for reach; program awareness and participation from the follow-up employee survey (n = 1306, representing 76% [range, 56%-100%] of the sample); change in fruit and vegetable consumption from a comparison between the follow-up and baseline surveys (n = 1359, representing 87% [range, 75%-100%] of the sample).

RESULTS

A higher number of activities per employee was significantly correlated with greater program awareness (.68; p = .006) and greater change in fruit and vegetable consumption (.55; p = .04). Greater participation in activities was significantly correlated with greater awareness (.67; p = .007), higher participation (.61; p = .02), and increase in fruit and vegetable consumption. (.55; p = .04).

CONCLUSIONS

These results provide quantitative indicators of a dose-response relationship between the number of intervention activities per employee and higher percentage of employee participation and observed increases in fruit and vegetable consumption.

The use of an interactive software program for quantitative characterization of microcalcifications on digitized film-screen mammograms

RATIONALE AND OBJECTIVES

Mammography is relatively nonspecific for the early detection of breast cancer. This study evaluates the accuracy of mammographic interpretation using quantitative features characterizing microcalcifications, which are extracted by a computerized system.

METHODS

A computer-aided diagnosis (CAD) system enabling digitization of film-screen mammograms and automatic feature extraction was developed. A classification scheme (discriminant analysis) based on these features was constructed and trained on 217 cases with known pathology. The diagnostic performance of the classification scheme was tested against the radiologist's conventional interpretation on 45 additional cases of microcalcifications, each analyzed independently by four radiologists.

RESULTS

The sensitivity of the CAD system analysis (95.7%) was significantly better than that of conventional interpretation (84.8%). The positive predictive value of interpretation increased significantly, as did the area under the receiver operating characteristic curve.

CONCLUSIONS

This classification scheme for microcalcifications, based on quantitative features characterizing the lesion, significantly improved the accuracy of mammographic interpretation.

Adaptation to pregnancy in three different ethnic groups: Latin-American, African-American, and Anglo-American

Interview assessments on adaptation to pregnancy were made of Latin-American (N = 30), African-American (N = 34), and Anglo-American (N = 30) women in the latter half of their pregnancy. Most subjects were 18-27 years old, single, had 12 years or less education, and had a parity of 0 or 1. Psychosocial measures of adaptation to pregnancy included Acceptance of Pregnancy, Identification with Motherhood Role, Relationship with Mother and with Husband/Partner, and Preparation for Labour. Data were analyzed using chi-square for group differences. The results indicate that in all 3 groups pregnancy was unplanned but wanted. African Americans least often anticipated life changes as a result of pregnancy, cited fewest aspects of pregnancy that were gratifying to them, and least often chose to stay home with their infant. Most women in all ethnic groups reflected on their role as mother, but Latin Americans most often indicated that they wanted to be like their own mother and that they consulted with their mother about pregnancy and parenting. African Americans least often anticipated domestic help from their partner and most often expected help from other family members. Regarding intimate relationships with husband/partner, for all groups sexual intercourse decreased during pregnancy. Anglo-Americans reported the least number of problems/discomforts with intercourse, Latin Americans the most. Anglo-Americans most often found alternative methods of sexually satisfying their partner, African Americans least often. The results of this exploratory study have significance for differences in the delivery of health care to the 3 ethnic groups and warrant further research.

Increasing fruit and vegetable consumption through worksites and families in the treatwell 5-a-day study

OBJECTIVES

We report on the results of the Treatwell 5-a-Day study, a worksite intervention aimed at increasing consumption of fruits and vegetables.

METHODS

Twenty-two worksites were randomly assigned to 3 groups: (1) a minimal intervention control group, (2) a worksite intervention, and (3) a worksite-plus-family intervention. The interventions used community-organizing strategies and were structured to target multiple levels of influence, following a socioecological model. Data were collected by self-administered employee surveys before and after the intervention; the response rate was 87% (n = 1359) at baseline and 76% (n = 1306) at follow-up. A process tracking system was used to document intervention delivery.

RESULTS

After control for worksite, gender, education, occupation, race/ethnicity, and living situation, total fruit and vegetable intake increased by 19% in the worksite-plus-family group, 7% in the worksite intervention group and 0% in the control group (P = .05). These changes reflect a one half serving increase among workers in the worksite-plus-family group compared with the control group (P = .018).

CONCLUSIONS

The worksite-plus-family intervention was more successful in increasing fruit and vegetable consumption than was the worksite intervention. Worksite interventions involving family members appear to be a promising strategy for influencing workers' dietary habits.

Analysis of clustered microcalcifications by using a single numeric classifier extracted from mammographic digital images

RATIONALE AND OBJECTIVES

The authors prospectively tested the performance of a single numeric classifier constructed from a discriminative analysis classification system based on automatic computer-extracted quantitative features of clustered microcalcifications.

MATERIALS AND METHODS

Mammographically detected clustered microcalcifications in patients who had been referred for biopsy were digitized at 600 dpi with an 8-bit gray scale. A software program was developed to extract features automatically from digitized images to describe the clustered microcalcifications quantitatively. The significance of these features was evaluated by using the Wilcoxon test, the Welch modified two-sample t test, and the two-sample Kolmogorov-Smirnov test. A discriminant analysis pattern recognition system was constructed to generate a single numeric classifier for each case, based on the extracted features. This system was trained on 137 archival known reference cases and its performance tested on 24 unknown prospective cases. The results were evaluated by using receiver operating characteristic analysis.

RESULTS

Thirty-seven extracted parameters demonstrated a statistically significant difference between the values for the benign and for the malignant lesions. Seven independent factors were selected to construct the classifier and to evaluate the unknown prospective cases. The area under the receiver operating characteristic curve for the prospective cases was 0.88.

CONCLUSION

A pattern recognition classifier based on quantitative features for clustered microcalcifications at screen-film mammography was found to perform satisfactorily. The software may be of value in the interpretation of mammographically detected microcalcifications.

GLOBALIZATION AND THE FUTURE OF CULTURE AREAS: Melanesianist Anthropology in Transition

▪ Abstract  In the last decade, anthropology has faced challenges to its self-definition associated both with new worldly circumstances and scholarly trends inside and outside the discipline. Recent interest in globalization has provoked discussion concerning what anthropology should be about, how it might be done, and what its relationships are to other bodies of literature and knowledge practices. Unsettling questions have been raised about working concepts of culture, ethnography, the field, fieldwork, and comparative analysis. Extending the rethinking of “place” in anthropology begun by Appadurai, I consider the future of “culture areas” as discursive frameworks for organizing disciplinary practices. Some characteristics of anthropological regionalism are located by contrasting them to interdisciplinary area studies, insofar as globalization poses apparently similar challenges to each. Because of its iconic disciplinary status as an exemplar of “real” anthropology, Melanesianist ethnography is given extended consideration as a particularly interesting case.

Adaptation to pregnancy and motherhood among subfecund and fecund primiparous women

OBJECTIVE

To examine the effects of infertility treatment on women's ability to adapt to pregnancy and motherhood.

METHODS

Fecund (n = 261) and subfecund (n = 103) primiparous women receiving obstetrical care in southeastern Michigan participated in this descriptive, correlational, prospective study. The subjects completed Lederman's Pre-Natal Self-Evaluation questionnaire during the third trimester of pregnancy and Lederman's Postpartum Self-Evaluation questionnaire during the first postpartum appointment.

FINDINGS

Mean scores showed that the two groups of women were not significantly different with either adaptation to pregnancy or motherhood.

CONCLUSIONS & IMPLICATIONS FOR NURSING

Although subfecund women may experience stress in order to achieve a pregnancy, there do not appear to be any latent effects of this stress on their ability to adapt to pregnancy or motherhood.

Developing guidelines for local use: algorithms for cost-efficient outpatient management of cardiovascular disorders in a VA Medical Center

Local use of practice guidelines requires paying close attention to the concerns of the patient within the framework of society, to the professional and educational needs of the provider, and to the realities of cost. One Veterans Affairs facility took the challenge of balancing these factors and developed their own algorithms for three cardiovascular disorders.

Ethnicity, maternal risk, and birth weight among Hispanics in Massachusetts, 1987-89

National data reveal that low birth weight and infant mortality rates among Hispanics are, in general, between the rates for whites and those for blacks. The question remains, do differences in low birth weight reflect distributions of known risk factors, or do ethnic differences persist after simultaneously adjusting for intervening variables? In this study, Massachusetts birth certificate data for 206,973 white non-Hispanic infants and 19,571 Hispanic infants are used to examine differences in low birth weight between white non-Hispanic and Hispanic infants, as well as variation among seven subgroups of Hispanic mothers--Puerto Rican, Dominican, Central American, South American, Mexican, Cuban, and other Hispanic. Regression analysis is used to estimate the association between risk factors and birth weight and the relative risk of low birth weight. Risk factors include ethnicity, demographic characteristics, biological factors, access to prenatal care, and infants' conditions. Results indicate substantial variation in mean birth weight, low birth weight, and levels of risk among Hispanic subgroups and between Hispanics and white non-Hispanics. Puerto Rican infants had the lowest mean birth weight and, in general, the highest level of risk factors in this population. None of the adjusted odds ratios for low birth weight for any Hispanic group was significantly elevated at the 95 percent level compared with white non-Hispanics. Findings in this study confirm the previous observations of the wide variation among Hispanic subgroups and the high level of risk among Puerto Ricans. Results of this study also raise some interesting questions about the differential relationship between ethnicity and birth weight, ethnicity and low birth weight, and the significance of maternal place of birth as a proxy measure of adaptation or acculturation.

Effects of Maine's 1981 and Massachusetts' 1982 driving-under-the-influence legislation

In 1981, Maine passed a drunk driving law with mandatory penalties and a new civil charge to increase the conviction rate. One year later, Massachusetts increased drunk driving penalties, particularly for repeat offenders and intoxicated drivers involved in fatal crashes. In Maine, single-vehicle nighttime fatal crashes declined 22 per cent the year before passage of the law, and 33 per cent the year after. Maine's rates returned to pre-law levels by the third post-law year. Prior to Massachusetts' new law, single-vehicle nighttime and overall fatal crashes there also declined 20% and 22%, whereas after this law fatal crash rates did not decline further compared with the pre-law year or other New England states. Pre- and post-law surveys indicate that both laws were followed by some increases in public perceptions that drunk drivers stopped by police would be arrested, convicted, and receive automatic penalties. But, few believed it was very likely that drunk drivers would be stopped. For only two of three years studied after Maine's law did more people there report decisions not to drive because they had drunk too much. In Massachusetts, reported driving after heavy drinking declined as much the year before as the three years after its law.

Aphasic status epilepticus: a case report

Complex partial status epilepticus with aphasia as the sole manifestation has been reported only twice before. We studied a 60-year-old diabetic who was aphasic for 12 days. The diagnosis of aphasic status was supported by electroencephalographic seizure patterns in the left hemisphere.