BEHAVIORAL MEDICINE ABSTRACTS A d d i c t i v e Behaviors

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370

A m e r i c a n H e a r t Journal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

370

A m e r i c a n Journal o f Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

371

A m e r i c a n Journal o f E p i d e m i o l o g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

372

A m e r i c a n Journal o f Public Health

376

A n n a l s o f Internal Medicine

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..........................................................................

377

A n n a l s o f Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

378

A r c h i v e s o f General Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

378

A r c h i v e s o f Neurology

378

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Arthritis Care and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

Arthritis a n d R h e u m a t i s m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

380

Biological Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

382

Cephalalgia

383

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Child D e v e l o p m e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

384

Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

384

Clinical Journal o f Pain

386

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Clinical P h a r m a c o l o g y a n d Therapeutics

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387

Controlled Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

388

D i a b e t e s Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

388

T h e D i a b e t e s Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

389

Diseases o f the Colon a n d R e c t u m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

390

Gastroenterology

390

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Headache ...........................................................................................

390

H e a d a c h e Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

391

H e a l t h Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

391

Hypertension ........................................................................................

393

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394

J o u r n a l o f A b n o r m a l Child Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

International Journal o f E p i d e m i o l o g y

395

J o u r n a l o f A b n o r m a l Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

395

J o u r n a l o f Adolescent H e a l t h

396

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J o u r n a l o f the A m e r i c a n A c a d e m y o f Child a n d Adolescent Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

396

J o u r n a l o f the A m e r i c a n Dental Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

397

J o u r n a l o f Behavioral Medicine

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397

J o u r n a l o f Clinical E p i d e m i o l o g y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

399

J o u r n a l o f Consulting a n d Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

399

J o u r n a l o f D e v e l o p m e n t a l a n d Behavioral Pediatrics

401

Journal of Epidemiology and Community Health

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402

Journal of Immunology ...............................................................................

402

Neurology

402

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N e w England Journal o f Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

405

Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

405

Pediatric Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

408

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

408

368

VOLUME 17, N U M B E R 4, 1995

Physical Therapy

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369

409

Psychological Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

409

Psychology a n d Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

410

Psychopharmacology .................................................................................

411

Psychophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

412

P s y c h o s o m a t i c Medicine

413

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Stress Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

414

V o l u m e 17, 1995: C u m u l a t i v e Subject Index

416

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370

ANNALS OF BEHAVIORAL MEDICINE

ADDICTIVE BEHAVIORS

174-0611

The Effects of Stress and Coping on Daily Alcohol Use in Women Breslin, F.C., O'Keeffe, M.K., Burrell, L., Ratliff-Crain, J., and Baum, A. 20(2):141-147, 1995. To evaluate the notion that perceived stress and drinking covary over time, daily logs were periodically collected over a 6-month period from 32 middle-aged women. Results indicated that significantly less alcohol was consumed on high-stress weeks than low-stress weeks. Problem-focused (P-F) coping preference moderated this relationship, with low P-F copers consuming more alcohol per occasion than did high P-F copers but only during low-stress weeks. These findings support a model of stress and alcohol use that includes coping preference as an important moderator of women's drinking. In addition, our data are consistent with the notion that stress can influence alcohol consumption but that low P-F women regulate their use, preferring to delay their drinking until after the termination of the stressor. Reprint Address: F.C. Breslin, Addiction Research Foundation, CRTI, 33 Russell Street, Toronto, ON M5S 2S1, Canada. 174-0612

Differences between Responders and Nonresponders to Cocaine Cues in the Laboratory Avants, S.K., Margolin, A., Kosten, T.R., and Cooney, N.L. 20(2):215-224, 1995. Previous research has shown that a majority of drug-dependent subjects respond to drug cues in the laboratory with increased craving; however, approximately one-third are not cue responsive. The current study examined differences between responders and nonresponders to cocaine cues in a sample of 69 cocaine-dependent methadone patients. Subjects completed questionnaires assessing selected dimensions of addiction and participated in a cue-reactivity protocol that assessed both cocaine craving and cocaine aversion in response to cues. Four groups of subjects were identified on the basis of their cue responses: (a) increased craving plus decreased aversion; (b) increasing craving only; (c) decreased aversion only; (d) no increase in craving and no decrease in aversion ("nonresponders"). No group differences were found in severity of cocaine dependence, depression, or on any demographic variable, with the exception of parental status. Group differences were found on measures of cocaine expectancies and self-efficacy. There is a discussion of the bearing of these findings upon explanations offered in the literature for nonreactivity to drug cues. Reprint Address: S.K. Avants, Yale School of Medicine, CMHC/Substance Abuse Unit, 34 Part Street, New Haven, CT 06519. Reliability of a Drug History Questionnaire (DHQ) Sobell, L.C., Kwan, E., and Sobell, M.B. 20(2):233-241, 1995. Drug abusers' self-reports are vital to clinical and research endeavors, yet few studies have explicitly examined the testretest reliability of drug abusers' reports of their pretreatment 174-0613

drug use. The present study evaluated the test-retest reliability of drug abusers' reports of (a) lifetime drug use using a drug history questionnaire (DHQ), and Co) demographic and drugrelated events. Intraelass and Pearson correlation coefficients revealed reasonably good reliability for most reports of drug use and related events. Further research needs in this area are discussed. Reprint Address: L.C. Sobell, Addiction Research Foundation, 33 Russell Street, Toronto, ON M5S 2S1, Canada.

AMERICAN HEART JOURNAL

174-0614

Relation between Insecurity and Type A Behavior

Price, V.A., Friedman, M., Ghandour, G., and Fleischmann, N. 129(3):488-491, 1995. This article presents a new Type A Videotaped Clinical Examination scale that measures insecurity. This scale was validated against an existing insecurity measure in a sample of 204 individuals. The results indicated that this new scale is a valid measure of insecurity. The relation between insecurity and type A behavior was examined in a sample of 3013 people. In this large population insecurity showed a strong positive correlation to type A behavior and to each of the two overt behavioral components, time urgency and free-floating hostility. Reprint Address: M. Friedman, Mt. Zion Medical Center, 1515 Scott Street, Suite 2, P.O. Box 7921, San Francisco, CA 94120.

174-0615

Left Ventricular Performance during Exercise Testing in Patients with Silent and Symptomatic Myocardial Ischemia Matsubara, K., Yokota, M., Miyahara, T., et at. 129(3):459-.464, 1995. We compared cardiohemodynamic response to dynamic exercise in 32 patients with exercise-induced silent or symptomatic myocardial ischemia. All patients had coronary artery disease without prior myocardial infarction and left ventricular hypertrophy. Patients underwent supine leg-exercise testing and received right heart catheterization. All patients exhibited ischemic ST-segment depression on electrocardiogram during exercise testing. They were classified retrospectively into two groups according to the absence (n = 10, group 1) or presence (n = 22, group 2) of chest pain induced by exercise. There was no significant difference between groups in the magnitude of peak STsegment depression. Pulmonary artery wedge pressure at peak exercise was significantly lower (p < 0.01), and the cardiac index was significantly higher (p < 0.01), in group 1 versus group 2. Our results indicate that exercise-induced left ventricular dysfunction is less severe in patients with silent myocardial ischemia than in those with symptomatic ischemia. Reprint Address: M. Yokota, Cardiovascular Section, Department of Clinical Laboratory Medicine, Nagoya University School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Japan, 466.

V O L U M E 17, N U M B E R 4, 1995

AMERICAN JOURNAL OF CARDIOLOGY

Effect of Epinephrine Infusion on Chest Pain in Syndrome X in the Absence of Signs of Myocardial Ischemia Eriksson, B., Svedenhag, J., Martinsson, A., and Sylv6n, C. 75:241-245,1995. Eight female patients (aged 51 to 65 years) with New York Heart Association class II angina pectoris, normal coronary angiograms, normal hyperventilation, and abnormal exercise stress tests (chest pain and ST depression), and 5 sex- and age-matched controls participated in this study. Epinephrine was given intravenously to both patients and controls at 5-minute intervals in doses of 0.1, 0.2, 0.3, 0.4, and 0.6 nmol/kg/min. After rest (15 minutes), the a-adrenoceptor antagonist phentolamine or placebo was administered intravenously to patients in a doubleblind, crossover study on 2 separate occasions in doses of 250 ~g/min for 5 minutes and 500 #g/rain for the next 10 minutes; the epinephrine infusion was repeated. Blood pressure, heart rate, and electrocardiogram were monitored continuously and pain was estimated on the Borg CR-l0 scale. On a third occasion, chest pain was induced in patients using the same epinephrine protocol during echocardiographic monitoring. In the control group, all patients received the maximal epinephrine dose. No chest discomfort or pain developed. In the patient group, the maximal tolerable epinephrine dose (0.39 +_ 0.19 nmol/kg/min) decreased diastolic pressure ( - 14 _ 9 m m Hg, p < 0.01) and increased heart rate (+24 _+ 10 beats/min, p < 0.01), not statistically different from the control group. Pulse pressure increased in the patient group (27 + 17 m m Hg, p < 0.01) but not in the controls. Left ventricular ejection fraction at baseline was within reference limits (58% to 75%) and did not change during epinephrine infusion. Chest pain, which was not different in quality, intensity, or location from the patient's habitual angina-like pain, was induced in 7 of the 8 patients, 4 of whom endured only a moderate dose of epinephrine. No ST depressions were observed. After administration ofphentolamine, chest pain developed to a degree similar to that with epinephrine alone. Chest pain is induced by epinephrine infusion in patients with syndrome X. Because no signs ofischemia occurred, a hypersensitive afferent cardiac nervous system may be an important cause of chest pain. Reprint Address: C. Sylv6n, Department of Medicine, Huddinge University Hospilal, S-141 86 Huddinge, Sweden. 174-0616

174-0617

Effects of Cardiac Rehabilitation and Exercise Training on Exercise Capacity, Coronary Risk Factors, Behavioral Characteristics, and Quality of Life in Women Lavie, C.J. and Milani, R.V. 75:340--343, 1995. Despite the known benefits of cardiac rehabilitation, limited data are available on the outcome of this treatment in women, and this secondary prevention strategy may be underutilized. To assess the gender differences in baseline exercise capacity, indexes of obesity, lipid profiles, behavior characteristics, and components of quality of life, as well as the improvements in these components after a secondary prevention pro-

371

gram, we retrospectively reviewed data from 458 patients (83 women and 375 men) enrolled in a phase II cardiac rehabilitation and exercise program after a major cardiac event. At baseline (6 weeks after the cardiac event and before rehabilitation), exercise capacity ( - 9 % , p = 0.08) and ratio of lowdensity lipoprotein cholesterol/high-density lipoprotein cholesterol ( - 14%, p < 0.01) were lower, but total cholesterol (+7%, p < 0.01), high-density lipoprotein cholesterol (+25%, p < 0.0001), low-density lipoprotein cholesterol (+8%, p < 0.01), and percent body fat (+ 15%, p < 0.0001) were higher in women than in men with corondry artery disease. In addition, with regard to quality of life, women had lower scores for energy (p = 0.06), function (p < 0.01), and total quality of life (p < 0.05) than men. After cardiac rehabilitation and exercise training, women had significant improvements in exercise capacity (+33%, p < 0.0001) and percent body fat ( - 7 % , p < 0.001), which compared favorably with the improvements (+40% and -5%, respectively) seen in men, but improvements in body mass index and lipids were not statistically significant. Although most behavioral traits and measures of quality of life significantly improved in women, depression, hostility, and measures of mental health were not significantly reduced. However, improvements in all these risk factors, behavioral traits, and components of quality of life were statistically similar in men and women. Because women have a lower exercise capacity, energy, function score, and total quality of life score at baseline, these improvements after cardiac rehabilitation may be of greater clinical benefit to women than to men. These data reaffirm that women should be routinely referred to and vigorously encouraged to participate in outpatient cardiac rehabilitation and exercise training after major cardiac events. Reprint Address: C.J. Lavie, Oehsner Heart and Vascular Institute, Section of Cardiology, 1514 Jefferson Highway, New Orleans, LA 70121.

174-0618

Circadian Variation of Ischemic Threshold in Syndrome X Lanza, G.A., Stazi, F., Colonna, G., et at. 75:683-686, 1995. To evaluate whether the ischemic threshold has a circadian rhythm in patients with syndrome X, we analyzed 90 episodes of ST depression detected on 24-hour Holter recordings of 12 such patients. Ischemic threshold was considered as heart rate (HR) at 1 m m ST depression. To correct for differences in basal HR among patients, however, the ischemic threshold was also calculated as a normalized index of H R at 1 m m ST depression: [(HR at 1 m m ST - 24-hour modal HR)/24-hour modal HR]. 100. Mean hourly values of both absolute and normalized HRs at I m m ST depression were obtained by grouping and averaging respective values of all episodes detected in every hour of the day in all patients. Chronobiologic analysis was performed by single cosinor method. A significant circadian rhythm was found for HR (mesor 76 beats/rain, amplitude 10 beats/rain, acrophase at 2:16 P.M., p < 0.001), number of episodes of ST depression (mesor 3.75, amplitude 2.9, acrophase at 2:45 P.M., p < 0.001) and cumulative time of ischemia, with a high correlation of distributions. Episodes of ST depression showed a double peak initially in the morning, and again in the afternoon. Both raw and normalized values of HR at 1 m m ST depression also had a significant circadian variation in ischemic threshold, which was lower in the night and early morning hours, pro-

372

ANNAI_,S O F B E H A V I O R A L M E D I C I N E

American Journal of Cardiology (continued) gressively increased until the first afternoon hours, and subsequently decreased in the evening. Normalized H R had a mesor of +20.5%, amplitude 14.5%, and acrophase at 2:55 P.M. (p < 0.01). Thus, our data demonstrate that ischemic episodes and ischemic threshold follow a significant circadian variation in patients with syndrome X. The similarity between the circadian rhythms of the episodes of ST depression and H R suggests a significant role of the increase in myocardial oxygen demand in the induction of ischemia. The significant circadian rhythm in ischemie threshold, however, indicates that variations in vasomotor tone have a remarkable role in the pathophysiologic mechanisms of transient ST-segment depression in these patients. Reprint Address: G.A. Lanza, Istituto di Cardiologia, Universith Cattolica del S. Cuore, L. go A. Gemelli, 8, 00168 Roma, Italy.

174-0619

Reporting of Coronary Risk Factors

75:716-717, 1995. Reprint Address:J. Abrams, School of Medicine, Cardiology Division, Department of Medicine, University of New Mexico, Albuquerque, NM 87131. Abrams, J.

174-0620

Long-Term Follow-up in Patients with Positive Exercise Test and Angiographically Normal Coronary Arteries (Syndrome X) Radice, M., Giudici, V., and Marinetti, G. 75:620--621, 1995. Reprint Address: M. Radice, Via Muratofi 29, 20100, Milano, Italy.

AMERICAN JOURNAL OF EPIDEMIOLOGY

174-0621

Teenage and Current Calcium Intake Are Related to Bone Mineral Density of the Hip and Forearm in Women Aged 30-39 Years Nieves, J.W., Golden, A.L., Siris, E., Kelsey, J.L., and Lindsay, R. 141(4):342-351,1995. The relation between diet and bone mineral density in premenopausal women was evaluated in a cross-sectional study of 139 women aged 30-39 years. The population consisted of volunteers recruited in Rockland County, New York, between September 1988 and August 1992. A food frequency questionnaire was used to determine nutrient intake for both the year prior to bone density measurement and for ages 13-17 years. Physical measurements included height, weight, grip strength, and percent body fat. Bone mineral density was measured in the lumbar spine, hip, and forearm. Multiple regression equations were used to relate nutrient intake to bone density while controlling for age, height, weight, and grip strength. There were no relations between lumbar spine or distal forearm bone density and any nutrient studied from either the current or teenage diet. Current dietary calcium intake was modestly related to hip bone density (~ = 0.077; p = 0.074). When fiber intake was added to the multiple regression model, the association between calcium and hip bone density was strengthened (fl = 0.10 l ; p = 0.037); this

would be expected, because fiber interferes with calcium absorption. In the teenage diet, phosphorus and calcium intake were related to hip bone density. A higher lifetime calcium intake was associated with a higher hip bone density compared with low lifetime calcium intake. An increase in teenage calcium intake from 800 to 1,200 mg per day is estimated to increase hip bone density by 6 percent. ReprintAddress:J.W. Nieves, Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY 10993.

174-0622

Spouse Support and Long-Term Adherence to Lipid-Lowering Diets Bovbjerg, V.E., McCann, B.S., Brief, D.J., et at. 141(5):451--460, 1995. Social support is inversely associated with heart disease risk. Support may influence heart disease by encouraging health behavior change in high-risk individuals. This study examined the association between spouse support and maintenance of lowfat diets in men with hypercholesterolemia. Participants were 254 men enrolled in a 24-month randomized trial of lipidlowering diets initiated in 1985 in Seattle, Washington. The Evaluation of Spouse Support, which assesses the extent to which spouses supported maintenance of lipid-lowering diets, was administered after the last of eight dietary classes and at 3, 12, and 24 months postinstruction. Attainment of dietary goals was determined from food records completed at the end of the class and at 3, 12, and 24 months. Compared with those in the lowest quartile, those in the highest quartile of support were more likely to attain dietary goals at 3 months (odds ratio (OR) = 4.5, 95% confidence interval (CI) 1.9-10.4), 12 months (OR = 5.5, 95% CI 2.4-12.5), and 24 months (OR = 3.9, 95% CI 1.7-9.3). Support was not associated with end-of-class dietary goal achievement. Social support may be an important factor in the maintenance of low-fat diets. Reprint Address: V.E. Bovbjerg, Northwest Lipid Research Clinic/Cardiovascular Behavioral Medicine Program, University of Washington, 1100 Olive Way, Suite 1430, Seattle, WA 98101. 174-0623

Nitrous Oxide and Spontaneous Abortion in Female Dental Assistants Rowland, A.S., Baird, D.D., Shore, D.L., et al. 141(6):531-538, 1995. The relation between anesthetic gas exposure and spontaneous abortion remains unresolved. We examined the effect of nitrous oxide on spontaneous abortion among female dental assistants. Questionnaires were sent to 7,000 dental assistants aged 18-39 years who were registered in California in 1987; 4,856 (69~ responded. Analysis was based on 1,465 respondents whose most recent pregnancy was conceived while working full time. Women were asked how many hours a week they worked with nitrous oxide during this pregnancy and whether the excess gas was scavenged (vented). Relative risk of spontaneous abortion (through week 20) was calculated using a person-week model. This allowed women with current pregnancies (130/o) or induced abortions (10%) to be included for appropriate time periods of risk. A total of I 01 pregnancies (7%) ended as spontaneous abortions. An elevation in risk of spontaneous abortion was seen among women who worked with nitrous oxide for 3 or more hours per week in offices not using scavenging

V O L U M E 17, N U M B E R 4, 1995

373

American Journal of Epidemiology (continued) equipment (relative risk -- 2.6, 95% confidence interval 1.35.0, adjusted for age, smoking, and number of amalgams prepared per week), but not among those using nitrous oxide in offices with scavenging equipment. This relation changed little when analyses were restricted to confirmed pregnancies or examined for several types of potential bias. Scavenging equipment appears to be important in protecting the reproductive health of women working with nitrous oxide. Reprint Address: A.S. Rowland, Epidemiology Branch A3-05, NIEHS, P.O. Box 12233, Research Triangle Park, NC 27709.

174-0624

mothers smoked at the time of the survey were more likely than children of nonsmoking mothers to experience wheezing respiratory illness (odds ratio = 1.36, 95% confidence interval 1.141.62). The association was greatest among children less than 2 years of age. The authors' estimate of the attributable risk in the US population indicates that maternal smoking is responsible for approximately 380,000 excess cases of childhood asthma/wheezing lower respiratory tract illness or 7.5% of the total number of such symptomatic children. Reprint Address: J.J. Stoddard, Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, H6/4 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792.

A Study of Milk and Calcium Supplement Intake and Subsequent Preeclampsia in a Cohort of Pregnant Women Richardson, B.E. and Baird, D.D. 141(7):667-673, 1995. To test the hypothesis that high calcium intake protects against preeclampsia, the relation between milk intake and preeclampsia was examined in a cohort of 9,291 pregnant women (7,104 White women and 2,187 Black women) selected from the Child Health and Development Study population assembled by the University of California, Berkeley, during 1959-1966. Exposure was based on glasses of milk per day with and without calcium supplements. Data from both White and Black women displayed a U-shaped distribution of preeclampsia risk in relation to milk and milk plus supplement intake. Logistic regression analysis showed that women who drank two glasses of milk per day had the lowest risk (reference category). The relative risk (RR) for those drinking one glass of milk per day was similarly low (RR = 1.2; 95 percent confidence interval (CI) 0.7-2.0), but risk for those drinking less than one glass of milk per day was substantially higher (RR = 1.9; 95 percent CI 1.22.9). Women drinking three or more glasses of milk per day also showed increased risk (RR = 2.0; 95 percent CI 1.2-3.4) as did those drinking four or more glasses per day (RR = 1.8; 95 percent CI 1.1-3.0). The increased risk associated with low milk intake is consistent with studies showing reduced blood pressure with increased calcium intake. The increased risk with high milk intake has not been demonstrated previously. Reprint Address: B.E. Richardson, Department of Veterinary Anatomy & Public Health, Texas Veterinary Medical Center, College Station, TX 77843-4458.

174-0626 Diet and Nuclear Lens Opacities Mares-Perlman, J.A., Brady, W.E., Klein, B.E.K., et al. 141(4):322-334, 1995. Relations between diet and nuclear opacities in the lens of the eye were investigated in a population-based cohort of middle-aged and older adults who lived in Beaver Dam, Wisconsin. Nuclear sclerosis was assessed from photographs of the lens taken during 1988-1990 in 1,919 persons in the Beaver Dam Eye Study. Diets in the past (1978-1980) were assessed retrospectively with the use of a food frequency questionnaire in home interviews. Relations with intake of foods and nutrients were evaluated using logistic regression analyses. In men, after controlling for age, smoking, and heavy drinking, intakes of numerous nutrients in the highest versus lowest quintile were associated with 40-50 percent reduced odds of more severe nuclear sclerosis. Relations with some nutrients (vitamins A, C, and E, riboflavin, thiamin, niacin) were at least partly explained by previously identified inverse associations with multivitamin use. Relations with other nutrients (folate, a-carotene, and dietary fiber) appeared to reflect associations with intake of foods, particularly vegetables. Inverse associations with individual nutrients and foods were often weaker or nonexistent in women. These data indicate that the intake of vitamin supplements (in men and women) and certain foods (particularly in men) may explain associations of several nutrients with risk for nuclear sclerosis. Reprint Address: J.A. Mares-Perlman, Department of Ophthalmology and Visual Sciences, University of Wisconsin, 610 North Walnut Street, 405 WARF, Madison, WI 53705-2397.

174-0625

174-0627

Impact of Parental Smoking on the Prevalence of Wheezing Respiratory Illness in Children Stoddard, J.J. and Miller, T. 141(2):96-102,1995. To quantitatively assess environmental tobacco smoke exposure from parental smoking as a risk factor for asthma or wheezing in childhood, and to derive estimates of excess asthma/ wheezing lower respiratory tract illness cases attributable to this risk factor, a cross-sectional analysis of the 1987 National Medical Expenditure Survey (a national probability sample of the civilian, noninstitutionalized US population) was undertaken. The National Medical Expenditure Survey included 7,578 children and youth less than 18 years of age in a stratified cluster sampling of US households. After using logistic regression analysis to control for sex, race/ethnicity, region of residence, population density, poverty status, maternal educational level, family size, and father's current smoking status, children whose

Physical Activity and Incidence of Diabetes: The Honolulu Heart Program Burchfiel, C.M., Sharp, D.S., Curb, J.D., et al. 141(4):360-368, 1995. Few prospective studies have assessed the relation between physical activity and diabetes. The authors examined this relation prospectively among 6,815 Japanese-American men in the Honolulu Heart Program who were aged 45-68 years and initially free of diagnosed diabetes in 1965-1968. A physical activity index was calculated based on time spent per day in different activity levels and a weighting factor correlated with estimated oxygen consumption. Incidence of clinically recognized diabetes was based on self-reported use of diabetic medication at one of two subsequent examinations. The age-adjusted 6-year cumulative incidence of diabetes decreased progressively with increasing quintile of physical activity from 73.8 to 34.3

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American Journal of Epidemiology (continued) per 1,000 (p < 0.0001, trend) in all men and from 53.9 to 21.7 per 1,000 (p < 0.0001, trend) among men with a non-fasting glucose level --10, indicative of mild to moderate symptoms of depression. There were 21 deaths during the follow-up period, including 19 from cardiac causes. Seven of these deaths occurred among patients who met DIS criteria for depression, and 12 occurred among patients with elevated BDI scores. Multiple logistic regression analyses showed that both the DIS (odds ratio, 3.64; 95% confidenee interval [CI], 1.32 to 10.05; P = .012) and elevated BDI scores (odds ratio, 7.82; 95% CI, 2.42 to 25.26; P = .0002) were significantly related to 18-month cardiac mortality. After we controlled for the other significant multivariate predictors of mortality in the data set (previous MI, Killip class, premature ventricular contractions [PVCs] of -> 10 per hour), the impact of the BDI score remained significant (adjusted odds ratio, 6.64; 95% CI, 1.76 to 25.09; P = .0026). In addition, the interaction of PVCs and BDI score marginally improved the model (P = .094). The interaction showed that deaths were concentrated among depressed patients with PVCs of -> 10 per hour (odds ratio, 29.1; 95% CI, 6.97 to 122.07; P < .00001). Conclusions Depression while in the hospital after an MI is a significant predictor of 18-month post-MI cardiac mortality. Depression also significantly improves a risk-stratification model based on traditional post-MI risks, including previous MI, Killip class, and PVCs. Furthermore, the risk associated with depression is greatest among patients with >--10 PVCs per hour. This result is compatible with the literature suggesting an arrhythmic mechanism as the link between psychological factors and sudden cardiac death and underscores the importance of developing screening and treatment programs for post-MI depression. Reprint Address: N. Frasure-Smith, Research Center, Montreal Heart Institute, 5000 Belanger Street East, Montreal, PQ HIT 1C8, Canada.

174-0670

Opposing Effects of Plasma Epinephrine and Norepinephrine on Coronary Thrombosis In Vivo Lin, H. and Young, D.B. 91(4):1135-1142, 1995. Background It is well known that plasma catecholamines and myocardial infarction have a close relation and that coronary artery thrombosis is a major cause of myocardial infarction. In addition, epinephrine is known to be a prothrombogenic agent in vivo. However, the role of the other major circulating catecholamine, norepinephrine, in the development of coronary thrombosis is somewhat uncertain, although the role of norepinephrine is often considered analogous to the role of epinephrine. Therefore, the present study was designed to investigate the effect of norepinephrine and its interaction with epinephrine on coronary thrombosis. Methods and Results To compare the effects of epinephrine and norepinephrine on coronary thrombosis, we analyzed the frequency of cyclic blood flow reductions (CFRs) in an anesthetized canine model of coronary thrombosis (n = 25). Three experiments were used in the present study. In the first experiment with epinephrine infusion, plasma epinephrine was elevated from 0.46 + 0.25 to 27.7 +

1.85 nmol/L. The frequency of CFRs increased by more than 60%, from 7.1 + 0.5 to 11.5 + 0.7 in 40 minutes (P < .01). The second experiment included three experimental periods: control, norepinephfine infusion, and norepinephrine infusion plus epinephrine infusion. Norepinephrine was infused to raise plasma norepinephrine from 1.3 +_ 0.2 to 32.4 + 4.3 nmol/L. The frequency of CFRs in the dogs was markedly reduced, from 7.89 + 0.42 to 2.41 + 1.08 in 40 minutes (P < .01), whereas arterial pressure was elevated from 88 - 3 to 118 ___5 m m Hg (P < .01). However, when epinephrine infusion was added to the norepinephrine infusion, the frequency of CFRs increased from 2.41 ___ 1.08 to 7.74 ___ 1.12 in 40 minutes (P < .01). In the third experiment, a servocontrol device was used during the norepinephrine infusion to prevent rises in coronary arterial pressure. As a result of the norepinephrine infusion, the frequency of CFRs was reduced from 7.47 --- 0.71 to 0.83 __. 0.65 in 40 minutes (P < .01), even though the coronary arterial pressure was not altered. Conclusions The present study demonstrated that infusion of epinephrine stimulated coronary artery thrombosis, whereas infusion of norepinephrine inhibited coronary artery thrombosis. In addition, the inhibitory effect of norepinephrine on coronary thrombosis is independent of increases in coronary arterial pressure. Therefore, the present findings suggest that epinephrine and norepinephrine have opposing effects on coronary thrombosis in dogs. Reprint Address: H. Lin, Department of Physiology and Biophysics, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505. 174-0671

Heart Rate Variability during Specific Sleep

Stages: A Comparison of Healthy Subjects with Patients after Myocardial Infarction Vanoli, E., Adamson, P.B., Ba-Lin, et al. 91(7):1918-1922, 1995. Background Heart rate variability (HRV) is typically higher during nighttime. This evidence supports the concept that overaU, sleep is a condition during which vagal activity is dominant. Myocardial infarction (MI) results in a loss in the overall nocturnal HRV increase. However, the characteristics of HRV during specific sleep stages in normal subjects and, more importantly, after MI, are unknown. This study describes HRV during sleep stages in normal subjects and in patients with a recent MI. Methods and Results HRV was measured from 5 minutes of continuous ECG recording in 8 subjects with no clinical evidence of coronary artery disease (age, 47 ___ 4 years) and in 8 patients with a recent MI (age, 51 +_ 2 years; NS versus control subjects) in the awake state, non-rapid eye movement (REM), and REM sleep. In normal subjects, the low- to high-frequency ratio (LF/HF) derived from power spectral analysis of HRV decreased significantly from the awake state to non-REM sleep (from 4 + 1.4 to 1.22 _+ 0.33, P < .01). During REM sleep, the LF/HF increased to 3 _+ 0.74 (P < .01 versus non-REM, NS versus awake). In post-MI patients, the LF/HF showed an opposite trend toward an increase from 2.4 _ 0.7 to 5.11 + 1.4 (NS, P < .01 versus the control subjects). REM sleep produced a further increase in the LF/HF up to 8.9 +__ 1.6 (P < .01 versus awake and versus REM in control subjects). Conclusions Myocardial infarction causes a loss in the capability of the vagus to physiologically activate during sleep. This results in a condition of relative sympathetic dominance even in a situation such as

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Circulation (continued) sleep, normally described as a condition of vagal dominance and, consequently, low risk for lethalevents. The evidence that the sleep-relatedvagal activation is lost after M I m a y providc new insightsto understanding the nocturnal occurrence of sudden death. Reprint Address: P.B.Adamson, DcpartrnentoflntcrnalMedicine,Cardiology Section,P.O. Box 26901, 5SP300, Oklahoma City,O K 73190.

174-0672

RR Variability in Healthy, Middle-Aged Persons Compared with Patients with Chronic Coronary Heart Disease or Recent Acute Myocardial Infarction Bigger Jr., J.T., Fleiss, J.L., Steinman, R.C., et al. 91(7):1936-1943, 1995. Background The purpose of this investigation was to establish normal values of RR variability for middle-aged persons and compare them with values found in patients early and late after myocardial infarction. We hypothesized that presence or absence of coronary heart disease, age, and sex (in this order of importance) are all correlated with RR variability. Methods and Results To determine normal values for RR variability in middle-aged persons, we recruited a sample of 274 healthy persons 40 to 69 years old. To determine the effect of acute myocardial infarction RR variability, we compared measurements of RR variability made 2 weeks after myocardial infarction (n = 684) with measurements made on age- and sex-matched middle-aged subjects with no history of cardiovascular disease (n = 274). To determine the extent of recovery of RR variability after myocardial infarction, we compared measurements of RR variability made in the group of healthy middle-aged persons with measurements made in 278 patients studied 1 year after myocardial infarction. We performed power spectral analyses on continuous 24-hour ECG recordings to quantify total power, ultralow-frequency (ULF) power, very-low-frequency (VLF) power, lowfrequency (LF) power, high-frequency (HF) power, and the ratio of LF to HF (LF/H10 power. Time-domain measures also were calculated. All measures of R R variability were significantly and substantially lower in patients with chronic ofsubaeute coronary heart disease than in healthy subjects. The difference from norreal values was much greater 2 weeks after myocardial infarction than l year after infarction, but the fractional distribution of total power into its four component bands was similar for the three groups. In healthy subjects, ULF power did not change significantly with age; VLF, LF, and HF power decreased significantly as age increased. Patients with chronic coronary heart disease showed little relation between power spectral measures of RR variability and age. Patients with a recent myocardial infarction showed a strong inverse relation between VLF, LF, and HF power and age and a weak inverse relation between ULF power and age. ULF power best separates the healthy group from either of the two coronary heart disease groups. Differences in RR variability between men and women were small and inconsistent among the three groups. Conclusions All measures of RR variability were significantly and substantially higher in healthy subjects than in patients with chronic or subacute coronary heart disease. The difference between healthy middle-aged persons and those with coronary heart disease was much greater 2 weeks after myocardial infarction than 1 year after infarction, but the fractional distribution of total power into its four component bands was similar for the healthy group and the two

coronary heart disease groups. Values of RR variability previously reported to predict death in patients with known chronic coronary heart disease are rarely (~ 1%) found in healthy middle-aged individuals. Thus, when measures of RR variability are used to screen groups of middle-aged persons to identify individuals who have substantial risk of coronary deaths or arrhythmic events, misclassification of healthy middle-aged persons should be rare. ReprintAddress: J.T. Bigger, Jr., Columbia University, P&S 9-445,630 West 168th Street, New York, NY 10032.

CLINICAL JOURNAL OF PAIN

174-0673

Secondary Gain Concept: A Review of the Scientific Evidence Fishbain, D.A., Rosomoff, H.L., Cutler, R.B., and Rosomoff, R.S. 11:6-21,1995. The "secondary gain" concept originated in the psychoanalytic literature, where it was never vigorously examined. The purpose of this review is to determine if there are scientific studies that have explored the validity of this concept. Design: A computer and manual literature review yielded 166 references in which primary, secondary, and tertiary gain were mentioned. Twenty-four (14.5%) of these reports were "secondary gain" studies. Fourteen "reinforcement" studies were also found. These 38 studies were grouped according to topics and reviewed in detail. Setting: Any medical treatment setting including pain treatment was utilized in the review procedure, i.e., no exclusion criteria. Patients: Any patient type, including those suffering from chronic pain, were utilized in the review procedure, i.e., no exclusion criteria. Results: A significant but limited number of studies have investigated the "secondary gain" concept, and the results of some of these studies are in conflict. Results of some studies, however, are remarkably consistent in supporting the importance of"secondary gain" to behavior. Some studies have methodological flaws, usually relating to how the presence of secondary gain was established. Conclusions: Overall the results of the reviewed studies support the potential importance of the "secondary gain" concept to understanding illness behavior and underscore a need for future research in this area. Reprint Address: D.A. Fishbain, University of Miami Comprehensive Pain and Rehabilitation Center at South Shore Hospital, 600 Alton Road, Suit 257, Miami Beach, FL 33139. 174-0674

Pain in Young Adults. II: The Use and Perceived Effectiveness of Pain-Coping Strategies

Lefebvre, J.C., Lester, N., and Kecfe, F.J. 11:36-44, 1995. Objective: The first goal of the study was to determine the internal reliability of the Coping Strategies Questionnaire (CSQ) in young adults. The second goal was to examine the relation of the CSQ to reported pain levels. The third goal was to investigate the relationship between the CSQ and concomitant pain problems. The fourth goal was to compare young adults

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Clinical Journal of Pain (continued) and different chronic pain samples in terms of the frequency of coping strategy use and perceived effectiveness of coping strategies. Design: The study included 252 undergraduate students who were given the CSQ, a demographic and pain level questionnaire, and a concomitant pain problem survey. Results: The results indicated that the CSQ was internally reliable when used to assess pain coping strategy use among young adults. Catastrophizing was found to be associated with both pain level and concomitant pain problems, with subjects reporting higher levels of catastrophizing having higher levels of pain and a higher frequency of both migraine headaches and low back pain. Finally, differences were found when comparing the perceived effectiveness in controlling and decreasing pain, and in the use of specific coping strategies in the young adult and chronic pain samples. The young adult sample reported a greater perceived efficacy in controlling and decreasing pain, compared to a sample of low back pain patients and a sample of myofacial pain patients. Conclusions: The results indicate that the CSQ is a reliable measure for the study of pain-coping strategies used in this population, and one that relates to differences reported in the experience of pain. Reprint Address: F.J. Keefe, Department of Psychiatry, Pain Management Program, Box 3159, Duke University Medical Center, Durham, NC 27710-3159. 174-0675

Predicting Subsequent Employment Status of SSA Disability Applicants with Chronic Pain

Rucker, K.S. and Metzler, H.M. 11:22-35, 1995. Objective: The study assessed the predictive ability of the standardized Multiperspective Multidimensional Pain Assessment Protocol (MMPAP). An assessment tool that predicts return to work with chronic pain patients is needed, as increasing numbers of disability applications are adjudicated in the courts. Design: National randomized validation sample of disability applicants. Each MMPAP consisted of physical examinations by two physiatrists and the participant's subjective assessment. Criterion standards were Multidimensional Pain Inventory and McGiU Pain Questionnaire. There was phone follow-up 6 months postdecision. Setting: Six clinical sites were ambulatory referral centers, both public and private. Participants: Population-based random national sample of 710 Social Security disability applicants claiming chronic pain related to their disability, stratified by national Social Security Administration (SSA) applicant demographics. Seventy-eight were lost to follow-up, and 688 initially refused. Interventions: No interventions were continued or initiated by the research team between assessment and follow-up. Main Outcome Measures: Claimant emptoyment status 6 months after disability decision was primary outcome, change in pain intensity, and change in employment situation. Results: The MMPAP predicted with 90% accuracy employment status of SSA disability applicants with chronic pain 6 months postdecision when assessed at application by two physicians trained in Physical Medicine and Rehabilitation (physiatry). Accuracy of employment situation change was 93%, and pain intensity change was 65%. Self-report measures, physical examination results, psychological status, functional limitations, and physician's subjective appraisal predict future employment. Conclusions: The MMPAP accurately predicts future employment of disability applicants claiming chronic pain. The introduction of this standardized protocol will assist in stan-

dardizing disability determination for claimants with chronic pain. Reprint Address: K.S. Rueker, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University/Medical Collegeof Virginia, Richmond, VA 23298.

CLINICAL PHARMACOLOGY AND THERAPEUTICS

174-0676

Regional Deposition of Inhaled "C-Nicotine Vapor in the Human Airway as Visualized by Positron Emission Tomography Bergstr~m, M., Nordberg, A., Lunell, E., Antoni, G., and I.~gstr6m, B. 57(3):309-317, 1995. The deposition of 11C-nicotine in the respiratory tract from a nicotine vapor inhaler was studied by means of positron emission tomography (PET) in an intrasubject comparison of six healthy smokers using two modes of inhalation: one with shallow, frequent inhalations ("buccal mode") and one with deep inhalations ("pulmonary mode"). An average of 15% of the radioactivity was released from the vapor inhaler after 5 minutes of inhalation. Approximately 45% of the dose released was found in the oral cavity. A significant amount of radioactivity, 10%, was observed in the esophagus, suggesting transfer of a major fraction of the dose to the stomach. Only a minor fraction, 5%, was found in the lungs, followed by 2% in the bronchi and 1% in the trachea. The deposition in the oral cavity closely foUowed a linear pattern during the 5 minutes of inhalation and was followed by a rapid elimination from the oral cavity, with an average half-life of 18 minutes. Only 8% of the dose released remained in the oral cavity 45 minutes after the end of inhalation. On the other hand, the dose fraction of about 14% distributed into the body tissue compartment at the end of inhalation had risen to 60% at that late time point. No statistically or clinically important differences were observed between the buccal and the pulmonary mode of inhalation in either deposition pattern or elimination rates. Reprint Address: E. Lunell, Pharmacia Consumer Pharma, Karl XI gatan 4, S-222 20 Lund, Sweden. 174-0677

Acute Physical Dependence: Time Course and Relation to Human Plasma Morphine Concentrations

June, H.L., Stitzer, M.L., and Cone, E. 57(3):270-280, 1995. Objectives: To characterize the postmorphine time course of precipitated withdrawal responses in comparison with the time course of opioid agonist effects and of plasma morphine concentrations. Background: The study provides a more detailed and comprehensive assessment of the postagonist time course of acute dependence effects in humans than previously available. Design: Opioid agonist effects, morphine plasma levels, and withdrawal effects precipitated by naloxone (10 rag/70 kg, administered intramuscularly) were examined at 1, 3, 6, 12, 18, 24, 30, 36, and 42 hours after a single dose of morphine (18 mg/70 kg, administered intramuscularly) in 10 nondependent opioid-experienced subjects. Results: The intensity of subjec-

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Clinical Pharmacology and Therapeutics (continued) tively reported precipitated withdrawal effects was greatest when testing was conducted at 6 hours after morphine administration, whereas peak intensity of agonist effects (pupil constriction and subjective ratings) and highest plasma morphine concentrations (57.3 ng/ml) were observed at the shortest test interval (1 hour) after morphine. Offset time course of naloxone-precipitated effects differed across specific measures, with hot and cold feelings elevated for the longest time after morphine (36 hrs), but significant effects were generally apparent for up to 24 hours after morphine pretreatment. Agonist effects lasted through only 12 hours; trace amounts of morphine were detected in plasma for up to 30 hours after administration. Conclusions: Results show that acute physical dependence engendered by a single dose of morphine peaks later and persists over a longer duration after morphine administration than do other agonist effects. This suggests that neuronal adaptations underlying physical dependence develop and decay gradually over time during a single episode of receptor occupancy. The presence of detectable morphine in plasma is consistent with a competitive displacement mechanism of precipitated effects, although noncompetitive actions of morphine or its metabolites are not ruled out. Reprint Address: H.L. June, Department of Psychologyand Program in Medical Neurobiology,Indiana University-PurdueUniversity, 402 North Blackford Street, Indianapolis, IN 46202.

174-0678

Alprazolam Absorption Kinetics Affects Abuse Liability Mumford, G.K., Evans, S.M., Fleishaker, J.C., and Grifliths, R.R. 57(3):356-365, 1995. Objective: To evaluate the behavioral, subjective, and reinforcing effects of immediate-release (IR) alprazolam and extended-release (XR) alprazolam to assess the effect of release rate on laboratory measures of abuse liability. Methods: Fourteen healthy men with histories of sedative abuse participated as subjects in a double-blind crossover study. All subjects received placebo, 1 and 2 mg immediate-release alprazolam, and 2 and 3 rag extended-release alprazolam in random order. Behavioral performance, subjective effects, and alprazolam plasma concentrations were assessed repeatedly 1/2hour before and 1/2, 1, 3, 5, 7, 9, 12, and 24 hours after drug administration. Results: Mean peak alprazolam plasma concentrations occurred 1.7 and 9.2 hours after immediate-release alprazolam and extendedrelease alprazolam, respectively. Compared to placebo, 2 rag immediate-release alprazolam impaired all measures of psychomotor and cognitive performance (Digit Symbol Substitution Test), motor coordination (circular lights and balance), and memory (digit entry and recall); 2 mg extended-release alprazolam did not affect any of these measures and 3 mg extendedrelease alprazolam impaired circular lights only. Immediaterelease alprazolam, 2 rag, increased all six measures of positive drug effects (e.g., ratings of liking or good effects); none of these measures were increased by 2 mg extended-release alprazolam and only three of the six measures were increased by 3 rag extended-release alprazolam. A drug versus money multiplechoice procedure designed to assess the relative reinforcing effects of each condition was administered 24 hour after the drug. The amount of money subjects were willing to "pay" to take the drug was significantly greater than placebo for both doses of immediate-release alprazolam but for neither dose of extended-release alprazolam. Conclusions: These data indicate that

extended-release alprazolam has less potential for abuse than immediate-release alprazolam. Reprint Address: R.R. Griitiths, 5510 Nathan Shock Drive, Baltimore, MD 21224.

CONTROLLED CLINICAL TRIALS

174-0679 An Empirical Evaluation of the Placebo Run-In Davis, C.E., Applegate, W.B., Gordon, D.J., Curtis, R.C., and McCormick, M. 16(1):41-50, 1995. A prerandomization placebo run-in period is often used in an attempt to exclude potential clinical trial participants who are likely to be poor adherers. It is assumed that potential participants who are poor adherers during the run-in will be less likely to take medication during the trial. This assumption was tested in the Cholesterol Reduction in Seniors Program (CRISP), by prescribing placebo for a 3-week period, but not using the results of the run-in as an entry criterion. The CRISP study was a pilot study designed to compare the effects on lipids and the safety of two doses oflovastatin and placebo in persons 65 years of age and older. After general entry criteria were satisfied, each participant was prescribed placebo for a 3-week period. At the end of the 3-week period, all participants were randomized to one of the three treatment groups, regardless of their adherence to the placebo. Of the 431 participants in the study, 66 (15%) who took less than 80% of the prescribed placebo or who failed to return their unused placebo pills were classified as poor runin adherers. Poor run-in adherence was associated with lower educational attainment. At 3 and 6 months of follow-up mean adherence was 89.3% and 83.4% among all participants. Exclusion of poor run-in adherers would have increased these means to 90.9% and 85.5%, respectively. Treatment effect as measured by fall in LDL cholesterol would have increased by 2.9 mg/dl in the 40 mg/day dose group at 3 months of follow-up with the addition of a placebo run-in. We conclude that a placebo runin would have had little effect on the outcome of the CRISP study and would have substantially increased recruitment difficulties. Lower educated persons were more likely to be excluded by a placebo run-in, but the effect of the run-in on followup adherence was stronger in less educated participants. More research about the role of a placebo run-in is needed in order to determine the appropriate role of this method in clinical trials. Reprint Address: C.E. Davis, Collaborative Studies Coordinating Center, Department of Biostatistics, Suite 203, 137 East Franklin Street, Chapel Hill, NC 27514.

DIABETES CARE

174-0680

Relationship between Habitual Physical Activity and Insulin Area among Individuals with Impaired Glucose Tolerance: The San Luis Valley Diabetes Study gegensteiner, J.G., Shetterly, S.M., Mayer, E.J., et at. 18(4):490-497, 1995. Objective-- To determine whether higher levels of physical activity are associated with lower fasting insulin levels and lower

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Diabetes Care (continued) insulin areas under the oral glucose tolerance curve in individuals with impaired glucose tolerance (IGT) in a community setting. Research Design and Methods--Data from a cross-sectional study of a population consisting of 219 Hispanic and nonHispanic white men and women with IGT (by World Health Organization criteria) in two rural Colorado counties were analyzed. Total physical activity was assessed by a 7-day physical activity recall, from which metabolic equivalents (METs) were estimated (expressed as MET h/week). Relationships of MET h/week with fasting insulin levels and insulin areas were assessed while considering obesity, age, and other risk factors known to influence fasting insulin level and insulin area. Results--Among all subjects, univariate analyses showed that higher physical activity levels were associated with lower mean insulin areas and fasting insulin levels (both P -< 0.05). Multiple linear regression showed that higher levels of physical activity were significantly associated with lower values of the insulin area (P < 0.001) but not with fasting insulin levels. The relationship between insulin area and habitual physical activity was independent of obesity, fat distribution, and age. Conclusions--On the basis of cross-sectional data, we conclude that higher levels of habitual physical activity are associated with lower insulin areas in a population of individuals with IGT. Understanding the impact of physical activity on markers of insulin action in individuals with IGT is important because of the greatly enhanced risk of non-insulin-dependent diabetes mellitus and, hence, cardiovascular disease in this population. Reprint Address: J.G. Regensteiner, Box B-180, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Denver, CO 80262.

1744)681

A Multicenter Evaluation of Blood Glucose Awareness Training-II Cox, D., Gonder-Frederick, L., Polonsky, W., et al. 18(4):523-528, 1995. Objective--Blood glucose awareness training (BGAT) teaches individuals with insulin-dependent diabetes to more accurately estimate/detect their blood glucose (BG) fluctuations. It has not, however, consistently resulted in improved ability to detect low BG. To assess an enhanced version of BGAT (BGAT-II), with more focus on increasing sensitivity to low BG events, a multicenter study was undertaken. Following up on previous findings that BGAT is most effective with individuals who are least accurate in estimating BG, this study explicitly recruited subjects who did and did not report reduced awareness of hypoglycemia. Research Design and Methods--Seventy-eight subjects from three research sites participated in a repeated baseline design. Subjects' BG estimation accuracy and BG profiles were assessed 6 months before, immediately before, and immediately after BGAT-II. Results--Post-treatment, BGATII led to better overall accuracy in detecting BG fluctuations and better detection of both low and high BG levels. This was achieved while the number of low readings of self-monitoring of blood glucose (SMBG) was reduced. Reduction in the number of low SMBG events was significant only for subjects reporting awareness of hypoglycemia. Detection of low BG was significant only for subjects reporting reduced awareness of hypoglycemia. Both groups demonstrated equivalent improvements in detection of high BG levels. Conclusions--BGAT may be an effective behavioral strategy for reversing hypoglycemic unawareness and

an adjunct to intensive insulin therapy to reduce the occurrence of severe hypoglycemia. Reprint Address: D.J. Cox, Box 223, University of Virginia Health Sciences Center, Charlottesville, VA 22908.

174-0682

A New and Simple Questionnaire to Identify People at Increased Risk for Undiagnosed Diabetes Herman, W.H., Smith, P.J., Thompson, T.J., Engelgau, M.M., and Aubert, R.E. 18(3):382-387, 1995. Objective--To develop a simple questionnaire to prospectively identify individuals at increased risk for undiagnosed diabetes. Research Design and Methods--People with newly diagnosed diabetes (n = 164) identified in the Second National Health and Nutrition Examination Survey and those with neither newly diagnosed diabetes nor a history of physician-diagnosed diabetes (n = 3,220) were studied. Major historical risk factors for undiagnosed non-insulin-dependent diabetes were defined, and classification trees were developed to identify people at higher risk for previously undiagnosed diabetes. The sensitivity, specificity, and predictive value of the classification trees were described and compared with those of an existing questionnaire. Results--The selected classification tree incorporated age, sex, history of delivery of a macrosomic infant, obesity, sedentary lifestyle, and family history of diabetes. In a representative sample of the U.S. population, the sensitivity of the tree was 79%, the specificity was 65%, and the predictive value positive was 10%. Conclusions--This classification tree performed significantly better than an existing questionnaire and should serve as a simple, noninvasive, and potentially costeffective tool for diagnosing diabetes in the U.S. Reprint Address: W.H. Herman, Epidemiology and Statistics Branch, Division of Diabetes Translation (K-10), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341-3724.

THE DIABETES EDUCATOR

174-0683

Diabetes Care Needs of Hispanic Patients Treated at Inner-City Neighborhood Clinics in New York City Engel, S., Shamoon, H., Basch, C.E., Zonszein, J., and Wylie-Rosett, J. 21(2):124-128, 1995. The charts of 254 Hispanic patients were selected from a sample of 321 patients with diabetes in four urban clinics that received federal funding to provide medical care in underserved communities. A standardized chart-audit protocol was used to assess the process of healthcare delivery and the presence of diabetes-associated comorbidities and complications in patients. Inconsistent recognition of obesity (11% identified vs 59% present), hyperlipidemia (17% identified vs 69% present), and renal dysfunction (3.5% identified vs 16% present) was evident on chart review. We also found inadequate compliance with current recommendations for diabetes care with respect to routine health screenings for diabetes-related complications,

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The Diabetes Educator (continued) recognition of comorbid diagnoses, and referral of patients for recommended specialty consultations. Issues specific to the varied Hispanic populations may need to be considered to improve the delivery of diabetes care for the growing Hispanic population with diabetes.

Reprint Address: J. Wylie-Rosett, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Belfer 1308, Bronx, NY 10461.

DISEASES OF THE COLON AND RECTUM

174-0684

Biofeedback for the Treatment of Fecal Incontinence: Long-Term Clinical Results Guillemot, F., Bouche, B., Gower-Rousseau, C., et al. 38:393-397, 1995. Biofeedback therapy has been proposed as a treatment for fecal incontinence with good, short-term results. PURPOSE: This study was designed to assess long-term clinical results of biofeedback therapy compared with medical therapy alone and to assess manometric results in patients treated with biofeedback. METHODS: Two groups of incontinent patients were studied. Group l consisted of 16 patients (3 males and 13 females; mean age, 59.9 years). Etiologies treated by biofeedback included descending perineum syndrome (7), postfistula or hemorrhoidectomy (4), and miscellaneous (5). Group 2 consisted of eight patients (two males, six females; mean age, 62.2 years). Etiologies treated with medical treatment alone (including enema and antidiarrheal therapy) included descending perineum syndrome (3), postfistula or hemorrhoidectomy (2), and miscellaneous (3). The incontinence score was initially 17.81 +_ 3.27 (standard deviation)in Group 1 and 17.0 +_ 2.77 in Group 2. Resting pressure of the upper and lower anal sphincter, maximum squeezing pressure, and duration of contraction were not initially different in Groups 1 and 2 but were significantly lower than in the control group of patients without incontinence (n = 12; 8 males, 4 females; mean age, 66.4 years) (P < 0.05). Followup duration was 30 months, with intermediate clinical score at 6 months for Group 1. RESULTS: After biofeedback therapy, the incontinence score at 30 months was lower in Group 1 (14.43 +_ 6.35 vs. 17.81 +_ 3.27; P < 0.035) and unchanged in Group 2 (18.0 _+ 2.72 vs. 17.0 _+ 2.77). However, in Group 1 the score at 6 months was much lower than at 30 months (6.31 + 7.81 vs. 14.43 _+ 6.35; P < 0.001). Only the amplitude of voluntary contraction and upper anal pressure (51.1 (range, 27-90) vs 36.7 (range, 20-80) mmHg) were significantly increased (81.5 (range, 55-120) vs. 62.1 (range, 30-90) mmHg; P < 0.05). CONCLUSION: Biofeedback improved continence at 6 months and at 30 months. However, the score at 6 months was much better, suggesting that the initial good results may deteriorate over a long time. These data suggest that it could be useful to reinitiate biofeedback therapy in some patients.

ReprintAddress:F. Guillemot, H6pital Claude Huriez, CHRU, F-59037 Lille Cedex, France.

GASTROENTEROLOGY

174-0685

Selective Dysfunction of Mechanosensitive Intestinal Afferents in Irritable Bowel Syndrome Accarino, A.M., Azpiroz, F., and Malagelada, J.-R. 108:636-643, 1995. Background/Aims: Experimental studies have shown gut hypersensitivity in irritable bowel syndrome. The aim of this study was to determine whether heightened perception of gut distention in irritable bowel syndrome is related to either decreased gut compliance, altered mechanosensitive afferents, or nonspecific sensory dysfunction. Methods: In 17 patients with irritable bowel syndrome and 15 healthy controls, stimulusrelated perception of (1) intestinal balloon distentions, (2) transmucosal electrical nerve stimulation (15 Hz, 100 #s), and (3) somatic transcutaneous electrical nerve stimulation (100 Hz, 100 #s) was measured. Individual stimuli of l-minute duration were randomly applied at 5-minute intervals. Results: Patients tolerated smaller intestinal volumes than controls (33 +_ 3 mL vs. 43 _+ 4 mL, respectively; mean _+ SE; P < 0.05), whereas both intestinal compliance and perception oftransmucosal electrical nerve stimulation were normal (patients tolerated 58 _+ 5 mA and healthy subjects tolerated 69 +_ 5 mA). Interestingly, patients perceived both stimuli more diffusely than controls; 48% _+ 9% distentions and 52% +_ 9% electrical stimuli were perceived over more than one abdominal region vs. 21% + 9% and 18% _+ 6%, respectively, in controls (P < 0.05 for both). In contrast to gut distentions, patients showed higher tolerance of somatic stimuli than controls (68 _ 7 mA vs. 42 _+ 6 mA, respectively; P < 0.05). Conclusions: Patients with irritable bowel syndrome show selective hypersensitivity of intestinal mechanosensitive pathways associated with a nonspecific, probably central dysfunction of viscerosomatic referral.

HEADACHE

174-0686

Anger, Depression, and Disability: A Path Analysis of Relationships in a Sample of Chronic Posttraumatic Headache Patients Duckro, P.N., Chibnall, J.T., and Tomazic, T.J. 35(1):7-9, 1995. Anger and depression are common affective concomitants of chronic headache. Previous research suggests that the affective component of headache may contribute to the patient's perceptions of the degree to which the headache is disabling. The present study examined the relationship between anger expression, anger suppression, depression, and headache-related disability (interference with function) in a sample of chronic posttraumatic headache patients. A path analytic model indicated a direct relationship between depression and perceived disability. Anger suppression and anger expression each had a direct influence on depression, but their effects on disability were mediated through depression. The results partially replicate a pre-

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Headache (continued) vious path analytic study of the relationships among these variables in a chronic headache sample, Reprint Address: P,N, Duckro, Department of Psychiatry and Human Behavior, Saint Louis University School of Medicine, f221 South Grand Boulevard, St. Louis, MO 63104.

174-0687 Headache and Quality of Life Cavallini, A., Micieli, G., Bussone, G., Rossi, F., and Nappi, G. 35(1):29-35, 1995. The present prospective-type study quantified, by way of an ad hoc questionnaire, the impact of the headache attack in its various manifestations and the effect of headache on the quality of life of 400 headache sufferers. In addition, the functional status of episodic headache patients has been compared to that of patients with chronic daily headache. We observed that during headache attacks, episodic headache patients were significantly more disabled by physical symptoms. On the contrary, patients with chronic daily headache showed a significantly greater occurrence of emotional disturbances. A difference was detectable for mental health which was significantly more compromised in chronic daily headache than in episodic headache patients (P < 0.05). During the interictal period, quality of life appeared more compromised in chronic daily headache than in episodic headache patients. Chronic daily headache subjects were characterized by higher disability scores in all the sections considered. The results of this investigation confirm that headache negatively influence a patient's quality of life not only during attack phases but also during interictal periods and underline the importance that future studies on the efficacy of headache treatments should also evaluate the impact on patient's quality of life. Reprint Address: A. CavaUini, Headache Centre, C. Mondino Foundation Via Palestro, 3, 27100 Pavia, Italy. 174-0688

MMPI and Critical Flicker Frequency (CFF) Analysis in Headache Patients with and without Drug Abuse Schnider, P., Maly, J., Mraz, M., et at. 35(1):17-20, 1995. Sixty-three headache patients (migraine: n = 28; tensiontype headache: n = 35) who fulfilled the IHS criteria of 'drug abuse' were investigated by means of the Minnesota Multiphasic Personality Inventory (MMPI) and the Critical Flicker Frequency (CFF) analysis. The results were compared to those of 63 headache patients without drug abuse (matched-pair easecontrol study). With respect to the MMPI results, no statistically significant differences between patients with drug abuse and patients without drug abuse were found. However, patients with drug abuse showed significantly decreased CFF values compared to patients without drug abuse. This was true both for patients with migraine and for patients with tension-type headache. Thus, CFF analysis may serve as a useful method to differentiate between headache patients with drug abuse and those without drug abuse. Reprint Address: P. Schnider, Neurologische Universit~tsldinik, W~hringer Giirtel 18-20, A-1090 Vienna, Austria. 174-0689

Migraine Consultations: A Triangle of Viewpoints Blau, J. N. and MacGregor, E.A. 35(2):104-106, 1995. Several studies have examined patients' attitudes to a consultation for migraine and other headaches. However, a patient's

assessment of the problem for which they seek treatment may differ from that of the referring primary physician which may, in turn, differ from the specialist's. This study set out to examine this triangle. The commonest reason for referral was failure of treatment response. This contrasted with the patient's different perception--an increase in the frequency of attacks which we saw as headaches additional 1o migraine, accounting for failed treatment. Similarly, our view of the patient wanting reassurance paralleled their request for further information. These findings confirmed the hypothesis that recognizing and understanding a patient's fears were important factors towards a favorable outcome of a consultation. Reprint Address: E.A. MacGregor, The City of London Migraine Clinic, 22 Charterhouse Square, London EC1M 6DX, England.

HEADACHE QUARTERLY

174-0690

Behavioral Patterns of Migralneurs during Attacks: A Functional Role?

Blau, J.N. and MacGregor, E.A. 6(1)'30-33, 1995. Objective: Study of migraineurs' behavior during attacks: therapeutic and conceptual implications. Design: Personal interview of patients by authors. Setting: Outpatients attending a Migraine Clinic. Patients: 50 migraineurs: 43 females and 7 males with migraine without aura (n ~ 38) or migraine with aura (n = 12). Main Outcome Measures: Proportion of attacks requiting bed-rest; if the curtains are drawn and why; if the door is shut and why; if they want to be alone and why; effect of sleep on attacks; other actions taken to alleviate symptoms. Results: 15 always went to bed, 8 went in two-thirds of attacks, 13 in one-third to one-half, 13 only rarely, and 1 never. 45/50 drew the curtains. 37/50 closed the bedroom door. 43/50 wanted solitude. 29/33 noted that sleep eased or resolved symptoms. Conclusion: The behavior of the 50 migraineurs during attacks showed remarkable similarity between individuals. This study supports the theory that withdrawal from stimuli, particularly by sleep, plays an important role in migraine therapy, possibly by restoring normal brain metabolism. Reprint Address: J.N. Blau, The City of London Migraine Clinic, 22 Charterhouse Square, London EC1M 6DX, United Kingdom.

HEALTH PSYCHOLOGY

174-0691

Effects of Psychosocial Interventions with Adult Cancer Patients: A Meta-Analysis of Randomized Experiments Meyer, T.J. and Mark, M.M. 14(2):101-108, 1995. Meta-analytic methods were used to synthesize the results of published randomized, controlled-outcome studies of psychosocial interventions with adult cancer patients. Forty-five

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Health Psychology (continued) studies reporting 62 treatment-control comparisons were identified. Samples were predominantly White, female, and from the United States. Beneficial effect size ds were .24 for emotional adjustment measures,. 19 for functional adjustment measures, .26 for measures of treatment- and disease-related symptoms, and .28 for compound and global measures. The effect size of 917 found for medical measures was not statistically significant for the few reporting studies9 Effect sizes for treatment-control comparisons did not significantly differ among several categories of treatment: behavioral interventions, nonbehavioral counseling and therapy, informational and educational methods, organized social support provided by other patients, and other nonhospice interventions. Reprint Address: T.J. Meyer, P.O. Box 84, Harrison, NJ 07029.

174-0692

Effects of Decreasing Sedentary Behavior and Increasing Activity on Weight Change in Obese Children Epstein, L.H., Valoski, A.M., Vara, L.S., et al. 14(2):109-115, 1995. Obese children 8-12 years old from 61 families were randomized to treatment groups that targeted increased exercise, decreased sedentary behaviors, or both (combined group) to test the influence of reinforcing children to be more active or less sedentary on child weight change9 Significant decreases in percentage overweight were observed after 4 months between the sedentary and the exercise groups ( - 19.9 vs. - 13.2). At 1 year, the sedentary group had a greater decrease in percentage overweight than did the combined and the exercise groups (-18.7 vs. - 10.3 and -8.7) and greater decrease in percentage of body fat ( - 4 . 7 vs. -1.3). All groups improved fitness during treatment and follow-up. Children in the sedentary group increased their liking for high-intensity activity and reported lower caloric intake than did children in the exercise group. These results support the goal of reducing time spent in sedentary activities to improve weight loss. Reprint Address: L.H. Epstein, Department of Psychology, Park Hall, SUNY, Buffalo, NY 14260. 174-0693

Resistance of Personal Risk Perceptions to Debiasing Interventions Weinstein, N.D. and Klein, W.M. 14(2):132-140, 1995. The tendency to believe that one's own risk is less than that of others may reduce interest in health-protective behaviors. This article describes 4 attempts to reduce such optimistic biases. In Study 1, New Jersey residents (N --- 222) were provided with lists of risk factors for several health problems. This manipulation was strengthened in Study 2 by presenting risk factors in such a way that participants (164 undergraduates) might see their own standing as inferior to that of others. In Study 3, risk factors were presented one at a time, and participants (190 undergraduates) incorporated them into a mental image of a highrisk individual. Finally, 374 undergraduates in Study 4 generated lists of personal attributes that they believed increased their risk. Optimistic biases were found in each study, but none of the manipulations reduced these biases consistently. In contrast, conditions using opposite manipulations often exacerbated the biases. Reprint Address: N.D. Weinstein, Department of Human Ecology, Cook College, Rutgers University, P.O. Box 231, New Brunswick, NJ 08903.

174-0694

Social Support, Coping, and Depressive Symptoms in a Late-Middle-Aged Sample of Patients Reporting Cardiac Illness Holahan, C.J., Holahan, C.K., Moos, R.H., and Brennan, P.L. 14(2):152-163, 1995. This study tests a 1-year predictive model of depressive symptoms in a late-middle-aged sample of patients reporting diagnoses of cardiac illness. Results based on 325 individuals (248 men and 77 women) diagnosed with chronic cardiac illness, 71 individuals (52 men and 19 women) diagnosed with acute cardiac illness, and 219 healthy controls ( 129 men and 90 women) strongly supported the hypotheses. Compared with healthy persons, individuals with chronic and those with acute cardiac illness reported more depressive symptoms at follow-up. Women overall showed more depressive symptoms than did men, and women with cardiac illness were particularly vulnerable to behavioral manifestations of depressive symptoms. Integrative time-lag and prospective structural equation models indicated that, for individuals with cardiac illness, social support and adaptive coping strategies predicted fewer depressive symptoms. Reprint Address: C.J. Holahan, Department of Psychology, University of Texas, Austin, TX 78712.

174-0695

Negative Affective Consequences of Thinking about Disease Detection Behaviors Millar, M.G. and Millar, K9 14(2):141-146, 1995. It was proposed that thinking about disease-detection behavior would lead to more negative moods than thinking about health-promotion behavior. Detection behaviors produce more negative moods because they can threaten perceptions of good health9 In a laboratory study, the initial mood states of 121 participants recruited from undergraduates and the general community were measured using a neutral-words rating procedure. Then participants were randomly assigned to think about performing a disease-detection behavior or a health-promotion behavior. Subsequently, they wrote down their responses to the behavior and evaluated these as either positive, negative, or neutral. Finally, the participant's mood was remeasured using both a neutral words-rating procedure and a more traditional bipolar rating measure. Results indicated that thought about disease-detection behavior produced more negative affective responses and more negative mood change than did thought about health-promotion behavior. Reprint Address: M.G. Millar, Department of Psychology, University of Nevada, Las Vegas, NV 89154-5030.

174-0696

Walking to Meet Health Guidelines: The Effect of Prompting Frequency and Prompt Structure Lombard, D.N., Lombard, T.N., and Winett, R.A. 14(2): 164-I 70, 1995. This study assessed the effects of frequency of prompting (phone calls once a week versus once every 3 weeks) and structure of prompting (high versus low structure) in 135 participants (132 women and 3 men) in a walking program designed to meet the American College of Sports Medicine's cardiovascular exercise goals. Survival analysis using 6 months of data points and using the criteria of walking at least 20 min a day for at

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Health Psychology (continued) least 3 times per week indicated an effect for more frequent versus less frequent prompting (46% and 13%) but not for highversus low-structure prompting (30% and 31%). The results suggested the efficacy of frequent prompting delivered in inexpensive ways as a means to increase exercise adherence and the further parametric study of other basic behavior change strategies. Reprint Address: D.N. Lombard, Office of Prevention and Health Services Assessment, Brooks Air Force Base, San Antonio, TX 78235.

174-0697

Relationship between Obesity and the Metabolic Effects of Smoking in Women Audrain, J.E., Klesges, R.C., and Klesges, L.M. 14(2):116-123, 1995. The influence of cigarette smoking on resting energy expenditure (REE) in normal-weight and obese smokers was investigated. Participants were 20 normal-weight and 20 obese female smokers assessed over a 2-day period. The results indicated that REE increased in both obese and normal-weight smokers after smoking, but the increase was greater for normalweight participants. The normal-weight group showed a 9.7%, 5.8%, and a 3.6% increase in REE during the three 10-min blocks constituting the 30-min postsmoking phase. However, the obese group showed a 3.9% and a 0.7% increase in REE and a 0.8% decrease in REE during this postsmoking phase. Between-group comparisons revealed a differential rate of change in REE after smoking, indicating that the obese group's change of REE at every postsmoking time point was on average 70 kcal/day below that of the normal-weight group. The metabolic effect of smoking is reproducible, and the obese smokers reliably show an attenuated effect. However, the reliability of the change is lower for both normal-weight and obese smokers. The results have potential implications for discouraging obese persons from taking up smoking and intervening among those who already smoke. Reprint Address: R.C. Klesges, Universities Prevention Center, Department of Psychology, University of Memphis, Memphis, TN 38152. 174-0698

The Effect of Smoking and Light Activity on Metabolism in Men Hultquist, C.M., Meyers, A.W., Whelan, J.P., et al. 14(2):124-131, 1995. This experiment examined the metabolic effects of smoking during rest and light activity under naturalistic conditions. Thirtynine male subjects first completed a submaximal graded exercise treadmill test to standardize activity level. Then 3 groups of subjects--smokers smoking (SS), smokers not smoking (SNS), and nonsmokers (NS)-were exposed to 3 stages of rest or 3 stages of light activity with order of rest or activity randomly determined over 2 different days. Energy expenditure was monitored continuously during these sessions. Significant increases in smokers' energy expenditure were observed during light activity when compared with smokers not smoking and nonsmokers. No differences were identified among groups at rest. These findings strengthen the conclusion that smoking or its components contribute to metabolic changes during typical levels of daily activity and suggest a mechanism for the frequently observed relationship between smoking status and body weight. Reprint Address: A. W. Meyers, Center for Applied Psychological Research, Department of Psychology, University of Memphis, Memphis, TN 38152.

HYPERTENSION

174-0699

Physiological Determinants of Hyperreactivity to Stress in Borderline Hypertension Sherwood, A., Hinderliter, A.L., and Light, K.C. 25(3):384-390, 1995. Blood pressure hyperreactivity during stress is characteristic of borderline hypertension in White men. The present study evaluated the hemodynamic basis of this hyperreactivity and assessed its physiological basis in terms of sympathetic nervous system function. Cardiovascular adjustments to an aversive reaction time test were compared with those of the forehead cold pressor test, representing stressors that elicit active behavioral responses in contrast to passive tolerance ofaversive stimulation. As anticipated, blood pressure increases were greater in 12 borderline hypertensive men compared with 21 agematched normotensive men during the active reaction time stressor but not during the passive cold pressor test. The pressor hyperreactivity in borderline hypertensives was associated with excessive rises in plasma epinephrine and norepinephrine, leading to greater increases in cardiac output, despite evidence that the cardiac #-adrenergic receptors in these subjects were downregulated compared with those of normotensive subjects. During the cold pressor test, borderline hypertension was associated with greater increases in systemic vascular resistance, which, in the presence of normal baroreceptor reflex function, led to an attenuation of cardiac output, thus producing no greater net effect on blood pressure than seen in normotensive subjects. Evidence of vascular hypertrophy in the borderline hypertensive subjects was considered to account for their vascular hyperreactivity to cold pressor stimulation. Collectively, the observations in this study further support the view that the early stages of hypertension in White men are characterized by sympathetic nervous system hyperreactivity, but only in association with tasks that elicit active behavioral coping responses. The extent to which these responses are elicited by typical daily events may be an important determinant of whether borderline hypertension matures to its established form, which displays hemodynamic characteristics dominated by vascular structural changes. Reprint Address: A. Sherwood, Box 3119, Duke University Medical Center, Durham, NC 27710. 174-0700

Job Status and High-Effort Coping Influence Work Blood Pressure in Women and Blacks Light, K.C., Brownley, K.A., Turner, J.R., et al. 25(4, Part 1):554--559, 1995. Work-related stress has been associated with an increased risk of hypertension and more severe cardiovascular problems in White men but has been less studied in women and Black men. To determine whether the trait of high-effort coping (John Henryism) was related to higher blood pressure during work and laboratory challenges, we studied a biracial sample of 72 men and 71 women working full time outside the home who underwent ambulatory blood pressure monitoring for one 8-hour workday. This was followed by laboratory monitoring of blood pressure during resting baseline and five brief stressors. Women

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Hypertension (continued) who were high-effort copers and had high status jobs had higher diastolic pressures at work and in the lab than other women; their pressure levels did not differ from those of men, but other women had lower pressures than men. In Blacks, the same combination of high-effort coping plus high job status was similarly associated with high work and laboratory diastolic pressure, as well as higher work systolic pressure. The trait of high-effort coping was observed in the large majority (71%) of the women and Blacks who had achieved high status jobs but was seen in a minority (36%) of White men with high status jobs and was unrelated to increased blood pressure in the latter group. Reprint Address: K.C. Light, CB #7175, Medical Building A, University of North Carolina, Chapel Hill, NC 27599-7175. 17441701

Insulin and Forearm Vasodilation in Hypertension-Prone Men

Hulth6n, U.L., Endre, T., Mattiasson, I., and Berglund, G. 25(2):214-218, 1995. Insulin-stimulated peripheral glucose uptake and insulinmediated forearm vasodilation were investigated in 38 normotensive men with a family history of hypertension (relatives) compared with 27 age- and body mass index-matched normotensive men with no family history of hypertension (control subjects). The euglycemic hyperinsulinemic clamp technique was used to measure peripheral glucose uptake (insulin sensitivity index) and the metabolic clearance rate of insulin. Intraarterial blood pressure and forearm blood flow were determined simultaneously, and forearm vascular resistance was calculated. The insulin sensitivity index was lower in relatives than in control subjects. The metabolic clearance rate of insulin was reduced and did not correlate to glucose disposal in the relatives as opposed to the control subjects. Forearm blood flow increased and forearm vascular resistance decreased to a similar extent in the two groups during the clamp. The vasodilator response was positively correlated to glucose disposal only in the relatives. In conclusion, impaired insulin-stimulated peripheral glucose uptake in normotensive sons from hypertensive families was accompanied by retained insulin-mediated forearm vasodilation. Thus, skeletal muscle blood flow supply does not seem to be the major determinant for glucose disposal. On the other hand, the positive correlation between glucose disposal and decrease in forearm vascular resistance in the relatives suggests that insulin-mediated vasodilation may be a limiting factor for peripheral glucose uptake in insulin-resistant individuals. Reprint Address: U.L. Hulthrn, Department of Endocrinology, Malta6 General Hospital, S-214 01 Malmr, Sweden.

INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

174-0702

A Case-Control Study of Physical Activity in Relation to Risk of Cancer of the Right Colon and Rectum in Men

Longnecker, M.P., Gerhardsson de Verdier, M., Frumkin, H., and Carpenter, C. 24(1):42-50, 1995. Background. Epidemiological data suggest that physical activity is modestly or moderately protective against colorectal

cancer. Additional data are needed to define better the slope of the dose-response curve and to clarify the types of activities that appear most protective. Methods. We examined the relation between occupational and vigorous leisure time physical activity and risk of cancer of the right colon and rectum in data from a case-control study conducted in New England from 1986 to 1988. We interviewed 163 cases with cancer of the right colon, 242 cases with cancer of the rectum, and 703 community controis. Results. Vigorous leisure time physical activity was associated with a decreased risk of cancer of the right colon; for men exercising ->2 hours per week the odds ratio was 0.60 (95% confidence interval [C1] : 0.35-1.00) compared with those who did not exercise. Adjustment for potentially confounding factors, including diet, had essentially no effect on the association. Self-reported occupational activity was less strongly related to risk of right colon cancer; the odds ratio for heavy work was 0.70 (95% C1 : 0.32-1.51). Occupational activity coded according to job title was essentially unrelated to risk of right colon cancer. An association between physical activity and decreased risk of rectal cancer was not present in these data. Conclusions. Our data add weight to the evidence that physical activity is related to decreased risk of colon cancer.

Reprint Address: M.P. Longnecker, Department of Epidemiology,UCLA School of Public Health, 10833 Le Conte Avenue, Los Angeles, CA 90024-1772.

17441703

Combined Oral Contraceptives and Risk of Cervical Carcinoma in Situ Ye, Z., Thomas, D.B., Ray, R.M., and the WHO Collaborative Study of Neoplasia and Steroid Contraceptives 24(1): 19-26, 1995.

Background. Although the possible influence of oral contraceptives on risk of cervical carcinoma in situ has been the subject of multiple prior investigations, the results have been inconsistent. Methods. Data from a multinational, collaborative case-control study were analysed to investigate further this possible relationship. To assess potential screening bias, some statistical analyses were restricted to subgroups of cases with and without symptoms at the time of their diagnosis. Results. Relative risk estimates in relation to various features of oral contraceptive use tended to be highest for asymptomatic disease, lowest for disease presenting with vaginal bleeding, and intermediate for disease presenting with other symptoms, suggesting the presence of a screening bias. In women with vaginal bleeding, who are least likely to have been detected by routine screening, no elevated risk of cervical carcinoma in situ was observed in relation to ever having used combined oral contraceptives, but there was an increased risk in users of over 60 months' duration. An increasing trend in risk with duration of use was most pronounced in these women who first used oral contraceptives in the past 5-10 years; and in women who used oral contraceptives for more than 60 months, risk declined with time since last use. Conclusion. These findings could reflect a reversible effect of long-term use of oral contraceptives at an intermediate stage in the carcinogenic process, or a non-causal relationship due to unidentified sources of bias or confounding.

Reprint Address: D.B. Thomas, The Fred Hutchinson Cancer Research Center, 1124 Colombia Street, Seattle, WA 98177.

V O L U M E 17, N U M B E R 4, 1995

International Journal of Epidemiology (continued) 174-0704 Dietary Factors and Stomach Cancer: A CaseControl Study in Korea Lee, J.-K., Park, B.-J., Yoo, K.-Y., and Ahn, Y.-O. 24(1):33-41, 1995. Background. Stomach cancer is the most common cancer among Koreans. There is wide agreement that dietary factors are important in gastric carcinogenesis, but the role of many Korean food items remains unknown. Methods. A case-control investigation involving 213 incident cases of histologically confirmed stomach cancer and an equal number of controls, matched by age (within 2 years) and sex, was conducted from June 1990 to October 1991. Results. An increased risk of stomach cancer was noted among those with high consumption of stewed foods such as soybean paste stew and hot pepper-soybean stew, broiled fish, and those who liked salty food. However, mung bean pancake, lofu (soybean curd), cabbage, spinach, and sesame oil decreased the risk of stomach cancer. Stratified analysis by salt in combined foods, such as stewed foods and pickled vegetables, disclosed salt as being an important risk factor. Analysis of cooking methods showed that broiling and salting increased the risk of stomach cancer, but that trying tended to decrease the risk. These results suggest that the cooking method might modify the gastric carcinogenicity of foods. As non-dietary factors, smoking and a family history of stomach cancer increased the risk, but use of a refrigerator decreased the risk of cancer. Conclusions. Heavy salt consumption and cooking methods like broiling and salting seem to play a major role in gastric carcinogenesis among Koreans. Reprint Address: Y.-O. Ahn, Department of Preventive Medicine, Seoul National University College of Medicine, 28 Yongon-dong, Chongnogu, Seoul 110-799, Republic of Korea. 174-0705

Alcohol Consumption and All-Cause Mortality

Duffy, J.C. 24(1):100-105, 1995. Background. Prospective studies of alcohol and mortality in middle-aged men almost universally find a U-shaped relationship between alcohol consumption and risk of mortality. This review demonstrates the extent to which different studies lead to different risk estimates, analyses the putative influence of abstention as a risk factor and uses available data to produce point and interval estimates of the consumption level apparently associated with minimum risk from two studies in the UK. Method. Data from a number of studies are analysed by means of logistic-linear modelling, taking account of the possible influence of abstention as a special risk factor. Separate analysis of British data is performed. Results. Logistic-linear modelling demonstrates large and highly significant differences between the studies considered in the relationship between alcohol consumption and all-cause mortality. The results support the identification of abstention as a special risk factor for mortality, but do not indicate that this alone explains the apparent U-shaped relationship. Separate analysis of two British studies indicates minimum risk of mortality in this population at a consumption level of about 26 (8.5 g) units of alcohol per week. Conclusions. The analysis supports the view that abstention may be a specific risk factor for all-cause mortality, but is not an adequate explanation of the apparent protective effect of alcohol consumption against all-cause mortality. Future analyses might better be performed on a case-by-case basis, using a change-point model to estimate the parameters of the relationship. The current mis-

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interpretation of the sensible drinking level of 21 units per week for men in the U K as a limit is not justified, and the data suggest that alcohol consumption is a net preventive factor against premature death in this population. Reprint Address: J.C. Duffy, Alcohol Research Group, Department of Psychiatry, Morningside Park, Edinburgh EHI0 5HF, Scotland, UK.

JOURNAL OF ABNORMAL CHILD PSYCHOLOGY

174-0706

Some Nontraditional (Unconventional and/or Innovative) Psychosocial Treatments for Children and Adolescents: Critique and Proposed Screening Principles

Arnold, L.E. 23(1):125-140, 1995. Five examples of nontraditional psychosocial treatments used for children/adolescents are reviewed: eye movement desensitization and reprocessing, electroencephalographic (EEG) biofeedback, deep pressure/touch therapies, stress-challenge treatments, and confrontational scare treatments. The generic recommendations from the September 1992 National Institutes of Health Conference on Unconventional Medical Treatments are summarized. Additional screening principles specific for psychosocial treatments are proposed and applied to the five treatments. The screens do not validate treatment efficacy or evaluate the quality of any previous research, but only facilitate decisions as to whether treatments deserve controlled investigation. Scientific evaluation of the nontraditional treatments reviewed could in general benefit from blinds (at least for assessment); control conditions matched for intensity, frequency, and duration (double blind where feasible); dose-response studies; testing of generalization and endurance supplements or boosters for quick, cheap treatments with time- or domainlimited effects; and comparing cost-effectiveness with established treatments. Two unscientific pitfalls must be avoided: embracing new treatments uncritically and rejecting them without fair examination. These pitfalls must be skirted without dissipating scarce research resources. Reprint Address: L.E. Arnold, Child and Adolescent Disorders Research Branch, NIMH, Parldawn 10-104, 5600 Fishers Lane, Rockville, MD 20587.

JOURNAL OF ABNORMAL PSYCHOLOGY

174-0707

Prospective Analysis of Personality and Behavioral Vulnerabilities and Gender Influences in the Later Development of Disordered Eating Leon, G.R., Fulkerson, J.A., Perry, C.L., and Early-Zald, M.B. 104(1):140-149, 1995. This article presents the 2-year findings of a prospective investigation of the precursors to the later development of an

396

ANNALS OF BEHAVIORAL MEDICINE

Journal of Abnormal Psychology (continued) eating disorder in adolescents. The sample consisted of 852 girls and 815 boys who began the study in Grades 7-10 and participated for 3 consecutive years. For both genders, the strongest predictors of Year 3 risk status were Years l and 2 risk scores. When the effects of Year 1 and Year 2 risk were controlled, race (Caucasian) and poor interoceptive awareness at Year 2 were significant predictors of disordered eating at Year 3 for girls. Previous risk status was the only significant predictor of Year 3 risk for boys. Gender difference evaluations in the risk score components indicated that a significantly greater proportion of girls than boys endorsed behaviors that were similar to eating disorder diagnostic criteria. Poor interoceptive awareness may provide a vulnerability for eating disorders; possible pathways were discussed. Reprint Address: G.R. Leon, Department of Psychology, University of Minnesota, Elliott Hall, 75 East River Road, Minneapolis, MN 55455.

JOURNAL OF ADOLESCENT HEALTH

174-0708

InformedConsent in Children and Adolescents: Age, Maturation and Psychological State Dorn, L.D., Susman, E.J., and Fletcher, J.C. 16:185-190, 1995. Purpose: The purpose of this investigation was to examine the relationship of understanding of research participation to anxiety, control, and stage of cognitive development. Methods: Participants included 44 boys and girls ages 7 to 20 years. All were inpatients for the first time in pediatric units of a research hospital. Twenty participants were admitted for experimental treatment of pediatric cancers and 24 were admitted for a 3-week treatment of extreme obesity. An interview was conducted to assess 12 elements of knowledge of research participation of a medical protocol. The interview was coded for: 1) knowledge of research participation score, 2) weighted knowledge of participation in research score (based on physician ratings of what was most-to-least important for children and adolescents to know), and 3) global control (perceived control over life, illness and treatment). A measure of anxiety and one Piagetian task to measure stage of cognitive development also were administered. Results: Pearson correlations, significant at p _< .05, were as follows: knowledge of participation in research and global control, (r = .40) and weighted knowledge of participation in research score and global control (r =.38). Hierarchical regression showed that the best predictors of knowledge of research participation or the weighted knowledge of research participation score was global control alone or an interaction of global control with anxiety. Conclusions: Emotional factors were more frequently related to understanding of research participation than age or cognitive development. Providing medical environments that decrease anxiety and increase control may enhance children's and adolescent's understanding of the research process. Reprint Address: L.D. Dora, University of Pittsburgh School of Nursing, 440 Victoria Building, Pittsburgh, PA 15261.

JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY

174-0709

Coping with Everyday and Disease-Related Stressors by Chronically Ill Children and Adolescents Spirito, A., Stark, L.J., Gil, K.M., and Tyc, V.L. 34(3):283-290, 1995. Objective: This study examines those aspects of disease that chronically ill children find stressful and the coping strategies they report using to manage these stressors. In particular, we examined whether a state or trait conceptualization of coping was most applicable to this population. Method: A total of 177 children with varying chronic illnesses were asked to complete a coping checklist in response to a self-generated illness-related problem and an everyday problem. Results: Analyses of coping strategy stability revealed gender but not age effects. Some coping strategies were used equally across varying illness-related stressors, but others, e.g. distraction, blaming others, and emotional regulation, varied by type of stressor. Moderately consistent patterns were found across illness-related and non-illness-related situations for the same individual. Conclusions: The results suggest that coping strategies used by chronically ill children have some stability but do vary across situations. Clinicians might benefit from routine screening of coping in chronically ill children. Reprint Address: A. Spirito, Child and Family Psychiatry, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.

174-0710

Case Study: A New Infection-Triggered, Autoimmune Subtype of Pediatric OCD and Tourette's Syndrome Allen, A.J., Leonard, H.L., and Swedo, S.E. 34(3):307-311, 1995. A review of clinical observations and literature reports leads to the hypothesis that, via a process analogous to Sydcnham's chorea, infections with group A E-hemolytic streptococci, among others, may trigger autoimmune responses that cause or exacerbate some cases of childhood-onset obsessive-compulsive disorder (OCD) or tic disorders (including Tourette's syndrome). If this hypothesis is correct, then immunological treatments should lead to decreased symptoms in some cases. Four cases with abrupt, severe onset or worsening of OCD or tics are presented from an open treatment study. All were boys aged 10 to 14 years. One had OCD, one had Tourette's syndrome, and two had both OCD and Tourette's syndrome. Clinically and on standardized rating scales, their symptoms were in the moderate to very severe range. Two had evidence of recent group A/3-hemolytic streptococci infections, and the others had histories of recent viral illnesses. Two were treated with plasmapheresis, one with intravenous immunoglobulin, and one with immunosuppressive doses of prednisone. All had a clinically significant response immediately after treatment. Diagnostic criteria are provided that describe these cases of pediatric, infectiontriggered, autoimmune neuropsychiatric disorders (PITANDs).

V O L U M E 17, N U M B E R 4, 1995

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Journal of the American Academy of Child and Adolescent Psychiatry (continued) Suggestions are made regarding the evaluation and management of patients who may have this condition. Reprint Address: A.J. Allen, Section on Behavioral Pediatrics, Child Psychiatry Branch, NIMH, Building 10, Room 6N240, 10 Center Drive MSC 1600, Bethesda, MD 20892-1600.

JOURNAL OF THE AMERICAN DENTAL ASSOCIATION

174-0713

174-0711

Temperament and Stress Resilience in SchoolAge Children: A Within-Families Study Smith, J. and Prior, M. 34(2):168-179, 1995. Objective: Stress resilience was assessed in 81 school-age children, from within 32 families acknowledging severe psychosocial stress. Resilient and nonresilient children, identified via competence and behavior disorder measures from school and home, were compared. Method: Parents and teachers completed questionnaires and rating scales, and children were observed and assessed at home on attributes of temperament, selfesteem, ability, gender, and mother-child warmth. Results: Individual differences in child and family attributes that were predictive of competent child functioning varied according to the outcome measure used. Teachers' ratings of positive temperament (low emotional reactivity, high social engagement) best discriminated children showing resilience on all indicators, i.e., behavioral and social competence both at home and at school, with maternal warmth and the number of adverse life events the child had recently experienced also contributing. Level of maternal stress and individual differences in child intelligence were related to academic adjustment, but the child's age, sex, ability, and self-concept were not significant discriminators of behavioral adjustment. Conclusions: The findings emphasize the salience of a positive temperament as a resilience factor as well as the need to consider different estimates and contexts in assessing resilience for children growing up in stressful situations. Reprint Address: J. Smith, Child Psychiatry Department, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia.

174-0712

Longitudinal Patterns of Heart Rate and Fighting Behavior in 9- through 12-Year-Old Boys Kindlon, D.J., Tremblay, R.E., Mezzacappa, E., et al. 34(3):371-377, 1995. Objective: To assess the temporal stability of heart rate and to examine its relationship with fighting behavior. Method: Heart rate at ages 9 through 12 was compared to a composite measure of fighting behavior in three cohorts of low socioeconomic status boys (n = 138; two cohorts of boys who had been rated as having disruptive behavior problems in kindergarten and one normative cohort) while controlling for body size, pubertal status, and level of family adversity. Results: Heart rate showed moderate stability at 1- and 2-year intervals in two of the three cohorts. The composite fighting score was related to heart rate for 11year-old boys in the normative cohort and 12-year-old boys in one of the disruptive cohorts. Conclusion: These data support the conclusion that there is a relationship between heart rate and aggression even within a low socioeconomic status sample. ReprintAddress:D.J. Kindlon, Department of Maternal and Child Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

A National Survey: Dentists' Attitudes Toward the Treatment of HIV-Positive Patients Bennett, M.E., Weyant, R.J., Wallisch, J.M., and Green, G. 126(4):509-514, 1995. The authors studied the attitudes of 1,000 U.S. dentists toward the treatment of HIV-positive patients. Using a randomsample mail survey, they measured dentists' professional attitudes toward treating HIWAIDS patients, fear of contagion and negative emotions toward HIV-positive patients. The results indicate that 68 percent of the respondents would treat an HIVpositive patient, even if the possibility for a legitimate referral exists. Reprint Address: M.E. Bennett, University of Pittsburgh School of Dental Medicine, Department of Dental Behavioral Science, 379 Salk Hall, Pittsburgh, PA 15261.

JOURNAL OF BEHAVIORAL MEDICINE

174-0714

Psychosocial Adaptation to Stoma Surgery: A Review Bekkers, M.J.T.M., van Knippenberg, F.C.E., van den Borne, H.W., et al. 18(1):1-31, 1995. During the last decade strong improvements have been made in the medical care of patients with a digestive tract stoma, particularly with regard to nursing skills and to the quality of collecting material for faecal products. Scientific investigation into the psychosocial adjustment of patients after stoma surgery has intensified as well, giving us indications for quality of life. These developments induced a review of the actual state of affairs in psychological issues. After evaluating the results of psychosocial stoma research, it can be concluded that the technical improvements in stoma care during the past decade did not result in a decline in psychosocial problems after stoma surgery. However, there are some serious problems when interpreting the results of studies in this field of investigation. Stoma surgery is not per se solely responsible for the reported psychosocial problems, first, because many conclusions are based on research studies with poor design and, second, because these studies lack a theoretical framework within which the process of psychosocial adjustment has been measured and explained. This review assesses the most current developments and controversies in this field. Reprint Address: M.J.T.M. Bekkers, The Netherlands Institute of Primary Health Care (NIVEL), P.O. Box 1568, 3500 BN Utrecht, The Netherlands.

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ANNALS OF BEHAVIORAL MEDICINE

Journal of Behavioral Medicine (continued) 174-0715

Do Cigarette Smokers Have Unrealistic Perceptions of Their Heart Attack, Cancer, and Stroke Risks? Strecher, V.J., Kreuter, M.W., and Kobrin, S.C. 18(1):45-54, 1995. This study examined whether perceived risks of heart attack, cancer, and stroke were higher among smokers than nonsmokers; whether smokers were more likely to underestimate these risks; and the demographic correlates of unrealistic risk estimation among smokers. Two thousand seven hundred eightyfive patients from 12 North Carolina family practices completed a questionnaire including a health risk appraisal and questions concerning smoking behavior and perceived risks of heart attack, cancer, and stroke. While most smokers accurately perceived their health risks to be greater than nonsmokers', smokers were also more likely to underestimate their risks. This optimistic distortion of risk was associated with age, gender, and education levels. Smokers may not yet understand the magnitude of health risks posed by smoking. These data suggest the need for renewed attention to perceptions of the health risks of smoking. As long as smokers underestimate their risks, they underestimate the imperative to quit. Reprint Address: V.J. Strecher, Health Communications Research Laboratory, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, NC 275997400. 174-0716

Postmastectomy Attitudes in Women Who Wear External Breast Prostheses Compared to Those Who Have Undergone Breast Reconstructions

Reaby, L.L. and Hort, L.K. 18(1):55-67, 1995. Sixty-four women who postmastectomy wore an external breast prosthesis and 31 women who had breast reconstruction participated in the present study. It was hypothesized that the breast prosthesis group would exhibit more negative attitudes towards their mastectomy experience compared to the breast reconstruction group. Using the Mastectomy Attitude Scale (MAS) the results indicated that both groups were satisfied with their bodies, had a positive outlook towards their lives, implied that sexuality entailed more than having breasts, and felt that mastectomy treatment was necessary to save their lives. Neither group concealed that they had a mastectomy, however, they were not prone to discuss their mastectomy experiences. The findings from the study indicate that the women postmastectomy already had or developed positive attitudes towards themselves and life in general and the method chosen for breast restoration had no apparent impact on these attitudes. Reasons for the sample's positive attitudes are discussed. 174-0717

Alcohol Use and Contraception in First Sexual Experiences Leigh, B.C., Schafer, J., and Temple, M.T. 18(1):81-95, 1995. Recent research has suggested that the use of alcohol or drugs in conjunction with sexual intercourse is associated with nonuse of contraception, particularly in first intercourse experiences. This paper reports findings from a nationally representative sample of adolescents and young adults aged 18-30 who were asked a number of questions about the circumstances and

characteristics of the first time they had intercourse. Results showed that drinking at the time of first intercourse was more prevalent among those who first had sex prior to 1985; moreover, members of this cohort were less likely to use condoms or other forms of birth control at the time of first intercourse. Drinking was associated with nonuse of contraception only among those who had their first sexual experience prior to 1985. The results are discussed in terms of historical changes in the sexual climate of the AIDS era. Reprint Address: J. Schafer, Alcohol Research Group, 2000 Hearst, Berkeley, CA 94709. 174-0718

Touch Relieves Stress and Pain

Fishman, E., Turkheimer, E., and DeGood, D.E. 18(1):69-79, 1995. There are few systematic investigations of the potential benefits of incidental touch as it occurs in medical health care settings. In the present laboratory study 60 college students participated in two testing sessions 1 month apart. These sessions involved counterbalanced conditions of baseline, pulse palpation (touch), cold pressor test (stressor), and combined cold pressor/pulse palpation. Heart rate and systolic and diastolic blood pressure were measured during each condition. Subjective pain ratings were recorded during stress conditions. Significant decreases in cardiovascular measures and pain ratings were associated with physical contact. However, these changes were small and individual responses to physical contact were not stable over time. Physical contact produces a small but significant decrease in cardiovascular variables and the experience of pain. However, the tendency to show a cardiovascular response to touch does not represent a stable trait for individuals in the laboratory setting. Reprint Address: E. Fishman, Department of Psychiatry, Medical College of Pennsylvania--Allegheny Campus, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772. 174-0719

Serum Cholesterol and Aggression in Hospitalized Male Forensic Patients Hillbrand, M., Spitz, R.T., and Foster, H.G. 18(1):33--43, 1995. Human studies of the link between serum cholesterol and aggression have yielded equivocal results. Depending on the type of aggression studied (e.g., criminal violence or Type A hostility), investigators have found either a negative or a positive association between cholesterol and aggressive behavior. We conducted a retrospective analysis of aggressive incidents in a sample of hospitalized male forensic patients. The whole sample had lower cholesterol levels than the general population. Patients with low cholesterol levels (< 200 mg/dl) engaged in more frequent aggressive behavior but showed no difference in severity of aggression. They also showed no difference in verbal vs physical aggression. The relationship between cholesterol and frequency of aggression was curvilinear, with the most frequent acts of aggression committed by patients with moderately low cholesterol levels. Current research findings regarding the cholesterol-aggression association suggest the need for further clarification of the behavioral parameters under investigation. Reprint Address:M. Hillbrand, Whiting Forensic Institute, Box 70, Middletown, CT 06457.

V O L U M E 17, N U M B E R 4, 1995

JOURNAL OF CLINICAL EPIDEMIOLOGY

174-0720 Maternal Build and Pregnancy Outcome Rantakallio, P., I.~di, E., Koiranen, M., and Sarpola, A. 48(2): 199-207, 1995. The effect of maternal build on the outcome of pregnancy was studied in two birth cohorts in Northern Finland, for 1966 and 1985-86. Prospectively collected data were available for 10,969 women in the earlier cohort and 9128 in the later one. The women in the earlier cohort were on average 2.9 cm shorter but 0.2 kg thinner and had 0.7 kg/m 2 greater BMI. 13% of the women in the earlier cohort had a BMI below 20, but 24% in the later one, while 96% in both cohorts had BMI below 30. The women with low BMI were on average taller than the others, and at all BMI levels the women of the earlier cohort were shorter and lighter than those of the later one. The outcome of pregnancy was measured by the incidence of pre-term births and perinatal plus childhood deaths up to the age of 4 years, and the association of maternal body measurements with low birth weight (

Behavioral medicine abstracts.

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