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Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin.The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum.These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

Pomalidomide, previously used to treat multiple myeloma, has been reported to cause acute pulmonary toxicity that improves with drug discontinuation. We present a case of delayed pneumonitis with persistent fibrosis associated with pomalidomide. A 61-year-old male treated with pomalidomide and corticosteroids presented with acute on chronic dyspnea, profound hypoxemia, and ground glass opacities on computerized tomographic imaging. Corticosteroid taper and discontinuation of pomalidomide resulted in clinical improvement, but with substantial residual pulmonary fibrosis. Given the temporal improvement, but not resolution, following discontinuation of an agent with an established propensity for lung injury, we attribute this presentation to pomalidomide toxicity.

Anemia is associated with increased morbidity and mortality in older adults. Diagnostic cutoff values for defining anemia vary with age, sex, and possibly race. Anemia is often asymptomatic and discovered incidentally on laboratory testing. Patients may present with symptoms related to associated conditions, such as blood loss, or related to decreased oxygen-carrying capacity, such as weakness, fatigue, and shortness of breath. Causes of anemia in older adults include nutritional deficiency, chronic kidney disease, chronic inflammation, and occult blood loss from gastrointestinal malignancy, although in many patients the etiology is unknown. The evaluation includes a detailed history and physical examination, assessment of risk factors for underlying conditions, and assessment of mean corpuscular volume. A serum ferritin level should be obtained for patients with normocytic or microcytic anemia. A low serum ferritin level in a patient with normocytic or microcytic anemia is associated with iron deficiency anemia. In older patients with suspected iron deficiency anemia, endoscopy is warranted to evaluate for gastrointestinal malignancy. Patients with an elevated serum ferritin level or macrocytic anemia should be evaluated for underlying conditions, including vitamin B12 or folate deficiency, myelodysplastic syndrome, and malignancy. Treatment is directed at the underlying cause. Symptomatic patients with serum hemoglobin levels of 8 g per dL or less may require blood transfusion. Patients with suspected iron deficiency anemia should be given a trial of oral iron replacement. Lower-dose formulations may be as effective and have a lower risk of adverse effects. Normalization of hemoglobin typically occurs by eight weeks after treatment in most patients. Parenteral iron infusion is reserved for patients who have not responded to or cannot tolerate oral iron therapy.

A total of 67 pairs of female roommates were randomized into a diet condition: (1) both ate normally; (2) one dieted, the other ate normally; and (3) both dieted. Adherence, weight loss, anxiety, depression, disordered eating symptoms, and stress were measured. Dieters lost more weight than non-dieters, but average loss was

The Survey of Organizational Research Climate (SOuRCe) is a new instrument that assesses dimensions of research integrity climate, including ethical leadership, socialization and communication processes, and policies, procedures, structures, and processes to address risks to research integrity. We present a descriptive analysis to characterize differences on the SOuRCe scales across departments, fields of study, and status categories (faculty, postdoctoral scholars, and graduate students) for 11,455 respondents from three research-intensive universities. Among the seven SOuRCe scales, variance explained by status and fields of study ranged from 7.6% (Advisor–Advisee Relations) to 16.2% (Integrity Norms). Department accounted for greater than 50% of the variance explained for each of the SOuRCe scales, ranging from 52.6% (Regulatory Quality) to 80.3% (Integrity Inhibitors). It is feasible to implement this instrument in large university settings across a broad range of fields, department types, and individual roles within academic units. Published baseline results provide initial data for institutions using the SOuRCe who wish to compare their own research integrity climates.

Background The risk of optic disc haemorrhages on visual outcome in idiopathic intracranial hypertension (IIH) is unknown. We report the type and frequency of optic disc haemorrhages and other funduscopic abnormalities at baseline in the study eye of the 133 subjects enrolled in the Idiopathic Intracranial Hypertension Treatment Trial completing 6 months of follow-up. Methods We reviewed optic disc photographs to tabulate the frequency and type of optic disc haemorrhages, other funduscopic abnormalities and papilloedema grades of the study eye at baseline and analyse if their presence is associated with a poor visual outcome. Results 27.2% of subjects had nerve fibre layer haemorrhages in at least one eye. Five of seven, 71% of subjects that met criteria for treatment failure, had nerve fibre layer haemorrhages in at least one eye (Fisher9s exact test: p=0.02). There was a good correlation between presence of nerve fibre layer haemorrhages and Frisen grade (Spearman9s correlation, p=0.002; r=0.271). Subjects with nerve fibre layer haemorrhages had a higher cerebrospinal fluid pressure (40.0 mm water, p=0.04). There was poor correlation between nerve fibre layer haemorrhages at baseline and the perimetric mean deviation change at 6 months. Cotton wool spots were present in 4% of subjects, exudates in 3% and pseudodrusen in 4%. Conclusions Nerve fibre layer haemorrhages are common in patients with IIH with mild visual loss and correlate with the severity of the papilloedema. They occur more frequently in treatment failure subjects and therefore may be associated with poor visual outcomes. Trial registration number NCT01003639, Post-results.

The effects of environmental stress exposure onListeria monocytogenesgrowth and virulence-associated characteristics were investigated. Specifically, we measured the effects of temperature (7 or 37°C), pH (5.5 or 7.4), the presence of salt and organic acids (375 mM NaCl, 8.45 mM sodium diacetate [SD], 275 mM sodium lactate [SL], or a combination of NaCl, SD, and SL), and deletion ofsigB, which encodes a key stress response regulator, on the ability ofL. monocytogenesto grow, invade Caco-2 cells, and survive exposure to synthetic gastric fluid (pH 2.5 or 4.5). Our results indicate that (i)L. monocytogeneslog-phase generation times and maximum cell numbers are not dependent on the alternative sigma factor σBin the presence of NaCl and organic acids at concentrations typically found in foods; (ii) growth inhibition ofL. monocytogenesthrough the addition of organic acids is pH dependent; (iii) the ability ofL. monocytogenesto invade Caco-2 cells is affected by growth phase, temperature, and the presence of salt and organic acids, with the highest relative invasion capabilities observed for cells grown with SL or NaCl at 37°C and pH 7.4; (iv) growth ofL. monocytogenesin the presence of NaCl, SD, or SL reduces its ability to survive exposure to gastric fluid; and (v) exposure ofL. monocytogenesto gastric fluid reduces the enhanced invasiveness caused by growth in the presence of NaCl or SL. These findings suggest that virulence-associated characteristics that determine theL. monocytogenesinfectious dose are likely to be affected by food-specific properties (e.g., pH or the presence of salt or organic acid).

Residential indoor concentration of asbestos, lead, synthetic vitreous fiber (SVF), crystalline silica, calcite, gypsum, dioxin, and polycyclic aromatic hydrocarbons (PAHs) were measured in 25 residences and 9 building-interior common areas in upper Manhattan, NY. This was done to characterize the background levels of contaminants, identified in dust related to the collapse of the World Trade Center towers, at locations that were minimally impacted by the dust fallout. The study was initiated due to the paucity of background concentrations on building-related materials and combustion byproducts in urban residential dwellings. Asbestos, lead, SVF, crystalline silica, and dioxin were detected at very low concentration at some locations, and many samples tested below their respective analysis detection limits. Almost all of the environmental samples for PAHs, calcite, gypsum, and certain other building materials tested below their respective analysis detection limits. A comparative analysis to the limited literature data showed general agreement with the values found in this study. This study provides insight into the levels of these contaminants in lower Manhattan residential buildings prior to the attack, and these data will serve to enhance the available database for characterizing indoor environments for these contaminants.

The concept of evidence-based medicine (EBM) has been widely adopted by orthodox Western medicine. Proponents of EBM have argued that complementary and alternative medicine (CAM) modalities ought to be subjected to rigorous, controlled clinical trials in order to assess their efficacy. However, this does not represent a scientific necessity, but rather is a philosophical demand: promoters of EBM seek to establish their particular epistemology as the primary arbiter of all medical knowledge. This claim is problematic. The methods for obtaining knowledge in a healing art must be coherent with that art's underlying understanding and theory of illness. Thus, the method of EBM and the knowledge gained from population-based studies may not be the best way to assess certain CAM practices, which view illness and healing within the context of a particular individual only. In addition, many alternative approaches center on the notion of non-measurable but perceptible aspects of illness and health (e.g., Qi) that preclude study within the current framework of controlled clinical trials. Still, the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials. Orthodox medicine should consider abandoning demands that CAM become evidence-based, at least as "evidence" is currently narrowly defined, but insist instead upon a more complete and coherent description and defense of the alternative epistemic methods and tools of these disciplines.

Portions of Montgomery County, Virginia, are designated a Medically Underserved Area with a large portion of this population experiencing limited access to healthcare services. In September 2008, the Federal Bureau of Primary Care awarded the authors a planning grant to assess community need in Montgomery County and to develop a strategic plan to establish a Federally Qualified Health Center (FQHC) to best meet these needs. An FQHC is a federally funded clinic mandated to provide medical, dental and mental health services to underserved communities. As part of the planning process, the decision was made to include qualitative data to better understand the needs of underserved residents in the community. Descriptive studies of target populations can provide further insight into community priorities for effective health improvement and planning. The objective of the study was to investigate and describe the perceptions, beliefs and practices that impact healthcare utilization among underserved populations in Montgomery County, Virginia. This study was conducted as part of a comprehensive community assessment to determine the feasibility of developing a FQHC.Community focus groups were conducted with target populations which were representative of the community. A thematic analysis of the transcribed field notes and group interviews was conducted. Qualitative data analysis was performed using the Analysis Software for Word-Based Records (AnSWR) developed by the Centers for Disease Control.Three important categories of beliefs which may impact healthcare utilization emerged from the discussions: (1) cultural health perceptions; (2) perceived barriers to care; and (3) coping strategies. Participants expressed a right to access quality care, preferred to spend money on basic living expenses rather than healthcare services; frequently neglected seeking care for adults while rarely neglecting to seek care for their children; valued but infrequently utilized preventative care; and had a lack of confidence in the care that was provided. Perceived barriers to healthcare services reported by participants included a lack of access to affordable care; complexities of health insurance and payer status; limited hours of clinic operation; lack of transportation and geographic distance; and the complexity of navigating the healthcare system. Finally, participants reported using various coping strategies to overcome barriers to accessing healthcare services. These strategies included delaying treatment and self-care; seeking financial and transportation assistance; and using community resources to navigate the system.Establishing care that is culturally relevant, targets perceived barriers and incorporates and enhances coping strategies is needed to increase accessibility and utilization of preventative and comprehensive healthcare services. The findings from this study will assist in creating a strategic plan for a FQHC that capitalizes on community strengths while addressing the challenges and complex needs of the community.

Objective: Smoking cessation policies are increasingly imposed in mental health facilities because of the high prevalence of tobacco smoking and its related adverse health consequences. The objective of this study was to measure the impact of 2 smoking cessation policies—one imposed in a specific psychiatric hospital and the other across the entire province of Ontario—on weekly visit rates to a psychiatric emergency department. Methods: Administrative data records from consecutive patient visits to a psychiatric emergency department were grouped by week from March 1, 2002, to December 31, 2005. The patients were grouped into 3 broad diagnostic categories: substance-related disorders, psychotic disorders, and other disorders. The impact of 2 smoking cessation policies—one imposed on September 21, 2005 at the Centre for Addiction and Mental Health (CAMH) and one imposed on May 31, 2006 across the province of Ontario—on psychiatric emergency department visit rates was measured using time series analysis. Results: The CAMH-specific smoking cessation policy had no impact on psychiatric emergency department visit rates in any diagnostic category. The province-wide smoking cessation policy resulted in a 15.5% reduction in patient visits for patients with a primary diagnosis of psychotic disorder. Conclusions: The benefits of a smoking cessation policy need to be balanced by the impact of the policy on the likelihood of patients to seek treatment.

Experimenters and teachers use discrimination learning procedures to encourage reliable attending to stimulus differences defined as relevant for their purposes. Put another way, the goal of discrimination training is to establish high-probability stimulus control topographies that are coherent with experimenter or teacher specifications. The present research was conducted to investigate a novel procedure for encouraging stimulus control topography coherence. Participants were 13 adolescents with severe intellectual handicaps. During an initial Condition A, all were exposed to a simultaneous discrimination procedure. Participants could select a form alternating with a black field (S+) or an identical form that did not alternate (S-). Accuracy scores were typically low, and there was little evidence of coherent stimulus control topographies. Subsequently, the procedure was changed. During Condition B, every trial initially presented two identical nonalternating S- forms (Trial State 1). If the participant made no selection for 5 s, one of the forms began to alternate with the black field, and he or she could make the S+/S- discrimination (Trial State 2). Selections during Trial State I prolonged the delay to Trial State 2 until there had been no response for 5 s. During Condition B, S+/S- discrimination accuracy scores improved rapidly and markedly for most participants. Reinstating Condition A often resulted in diminished accuracy scores. This study thus (a) demonstrated a novel procedure for encouraging stimulus control topography coherence and (b) provided support for the interpretation that intermediate accuracy scores may be due to different topographies of stimulus control that co-occur in the same discriminative baseline.

Experimental and observational data suggest that micronutrients with antioxidant capabilities may retard the development of age-related cataract.To evaluate the effect of a high-dose antioxidant formulation on the development and progression of age-related lens opacities and visual acuity loss.The 11-center Age-Related Eye Disease Study (AREDS) was a double-masked clinical trial. Participants were randomly assigned to receive daily oral tablets containing either antioxidants (vitamin C, 500 mg; vitamin E, 400 IU; and beta carotene, 15 mg) or no antioxidants. Participants with more than a few small drusen were also randomly assigned to receive tablets with or without zinc (80 mg of zinc as zinc oxide) and copper (2 mg of copper as cupric oxide) as part of the age-related macular degeneration trial. Baseline and annual (starting at year 2) lens photographs were graded at a reading center for the severity of lens opacities using the AREDS cataract grading scale.Primary outcomes were (1) an increase from baseline in nuclear, cortical, or posterior subcapsular opacity grades or cataract surgery, and (2) at least moderate visual acuity loss from baseline (/=15 letters). Primary analyses used repeated-measures logistic regression with a statistical significance level of P =.01. Serum level measurements, medical histories, and mortality rates were used for safety monitoring.Of 4757 participants enrolled, 4629 who were aged from 55 to 80 years had at least 1 natural lens present and were followed up for an average of 6.3 years. No statistically significant effect of the antioxidant formulation was seen on the development or progression of age-related lens opacities (odds ratio = 0.97, P =.55). There was also no statistically significant effect of treatment in reducing the risk of progression for any of the 3 lens opacity types or for cataract surgery. For the 1117 participants with no age-related macular degeneration at baseline, no statistically significant difference was noted between treatment groups for at least moderate visual acuity loss. No statistically significant serious adverse effect was associated with treatment.Use of a high-dose formulation of vitamin C, vitamin E, and beta carotene in a relatively well-nourished older adult cohort had no apparent effect on the 7-year risk of development or progression of age-related lens opacities or visual acuity loss.

Multiple gestations, or multifetal pregnancies, raise a number of significant policy questions concerning the well being of women and the well being of the children fetuses might become. Important questions for feminists pertain not only to multifetal pregnancy itself, but also to the medical interventions associated with these pregnancies. In this paper, we address the questions of how many embryos should be transferred in assisted reproduction, how many fetuses should remain in a multiple gestation, who should make these decisions, and the need to protect women from overexposure to exogenous hormones. Although we focus on assisted reproduction in the United States, we believe that our suggestions are applicable to other countries where the technology is comparable.

To provide data regarding safety and efficacy for women attempting a trial of labor following earlier cesarean birth who have reached their due date.A computerized data base was analyzed to identify women who were at or beyond 40 weeks of gestation between January 1, 1995, and March 31, 1996. Ninety women attempted vaginal birth after cesarean (VBAC) during the study period; 90 controls were matched for age, race and parity. Delivery route and complications were outcome variables identified.The rate of successful VBAC was 65.6% as compared to the 94.4% vaginal delivery rate among women who had not had a prior cesarean (P.0001). Among women attempting VBAC, 62% of those who had no prior vaginal births successfully delivered vaginally, while 82% of women with one prior vaginal birth delivered vaginally (P.0001). Women of greater parity were more successful at a trial of labor. Infectious morbidity was more common among women attempting VBAC than among those with no prior cesarean.The patient and her family can be reassured that passing her due date does not alter the efficacy or safety of a trial of labor. No change in counseling is warranted simply due to the completion of 40 weeks' gestation.

The ketogenic diet has been successfully used in treatment of pediatric epilepsy for70 years. Few serious complications caused by the diet have been reported. We report complications that have been experienced by children receiving the ketogenic diet.In a 22-month period, we treated 52 children with the classic ketogenic diet and monitored them in a prospective manner.Five children (10%) experienced serious adverse events (AE) after initiation of the diet. Four patients (80%) were treated with valproate (VPA) in addition to the diet, as compared with 25 (53%) of the other 47 children. Two patients developed severe hypoproteinemia within 4 weeks of initiation of the diet, and 1 of them also developed lipemia and hemolytic anemia. A third child developed Fanconi's renal tubular acidosis within 1 month of diet initiation. Two other children manifested marked increases in liver function tests, 1 during the initiation phase and the other 13 months later.Clinicians who wish to use the ketogenic diet must be aware of the potential of serious AE and possible interactions of the diet with VPA.

This review article discusses the evidence documenting the interrelationship between nutritional status and clinical outcome of the renal patient population. The limitations of accurately assessing the nutritional status of this patient group with commonly used indices are detailed. An overview of the history of nutrition supplementation as an intervention for the malnourished renal patient reveals that the efficacy of both enteral and parenteral methods has not been adequately explored to draw any firm conclusions. Based on available data, recommendations for providing nutrition care for the malnourished patient are provided. Therapeutics that are currently under investigation as future interventions for malnutrition are identified.

We retrospectively reviewed the cases of 10 consecutive patients treated with hemivertebral excision for congenital scoliosis at The Children's Hospital, Denver, CO, between 1982 and 1992. Follow-up consisted of physical and radiographic examination and averaged 54 months (range, 4-111). Age at surgery ranged from 9 months to 10 years, 5 months (average, 3 years, 11 months). Hemivertebra levels were between T12 and L3. The average preoperative curve measured 40 degrees (range, 20-55 degrees); the average at latest follow-up was 16 degrees (range, 3-37 degrees). We found hemivertebral excision for congenital scoliosis to be a safe and effective means of treatment. Curve correction averaged 67% and seemed to be greatest in those less than 4 years of age at the time of surgery.

PURPOSE: To determine whether relative cortical thickness measurements of the precentral and postcentral gyri can be used to differentiate the central sulcus from adjacent cortical sulci. METHODS: Turbo inversion-recovery MR imaging of the entire brain was done with scans parallel to the anterior commissure-posterior commissure line. Cortical thickness was measured in each hemisphere with a jeweler's eyepiece with 0.1-mm gradations. Three measurements were obtained perpendicular to the central, precentral, and superior frontal sulci, as determined by means of established anatomic methods. The ratios of cortical thickness on both sides of the central, precentral, and superior frontal sulci were calculated and compared. RESULTS: The mean ratio of precentral/postcentral gyri was 1.64 for the right hemisphere and 1.53 for the left hemisphere. The mean cortical thickness ratios were as follows: 1.01 for the right hemisphere and 3.01 for the left hemisphere across the precentral sulcus, and 1.03 for the right hemisphere and 0.99 for the left hemisphere across the superior frontal sulcus. CONCLUSION: Cortical thickness measurements across the central sulcus provide a method for locating the primary motor (precentral gyri) and primary somatosensory (postcentral gyri) cortices. The higher mean cortical thickness ratio across the central sulcus corresponds with known cytoarchitectonic relationships.

Huntington disease (HD) is an autosomal dominant degenerative disorder caused by an expanded and unstable trinucleotide repeat (CAG)n in a gene (IT-15) on chromosome 4. HD exhibits genetic anticipation--earlier onset in successive generations within a pedigree. From a population-based clinical sample, we ascertained parent-offspring pairs with expanded alleles, to examine the intergenerational behavior of the trinucleotide repeat and its relationship to anticipation. We find that the change in repeat length with paternal transmission is significantly correlated with the change in age at onset between the father and offspring. When expanded triplet repeats of affected parents are separated by median repeat length, we find that the longer paternal and maternal repeats are both more unstable on transmission. However, unlike in paternal transmission, in which longer expanded repeats display greater net expansion than do shorter expanded repeats, in maternal transmission there is no mean change in repeat length for either longer or shorter expanded repeats. We also confirmed the inverse relationship between repeat length and age at onset, the higher frequency of juvenile-onset cases arising from paternal transmission, anticipation as a phenomenon of paternal transmission, and greater expansion of the trinucleotide repeat with paternal transmission. Stepwise multiple regression indicates that, in addition to repeat length of offspring, age at onset of affected parent and sex of affected parent contribute significantly to the variance in age at onset of the offspring. Thus, in addition to triplet repeat length, other factors, which could act as environmental factors, genetic factors, or both, contribute to age at onset. Our data establish that further expansion of paternal repeats within the affected range provides a biological basis of anticipation in HD.

This article responds to two papers: one describing and defending the intracardiac injection of potassium chloride (KCl) to achieve immediate cardiac arrest in fetuses destined for second-trimester abortion because of abnormalities and a second, accompanying, paper that replies to objections to KCl injection and presents positive arguments for the use of KCl. This response concurs with the moral acceptability of the use of KCl and goes further to argue for its use in late elective abortions of nonanomalous fetuses. The response, however, while agreeing with the conclusions of the arguments presented in the second paper, finds the reasoning set forth in the arguments to be faulty. The objections to the procedure addressed in the second paper are that all abortions are unjust, that newborns and second-trimester fetuses with identical defects should be managed in like manner, and that a woman is not entitled to the death of her fetus. The arguments presented in the second paper to defend KCl use are that the abortion decision is protected by the right to noninterference, that potential harm is avoided by the procedure, and that the potential for coercion is eliminated. Abortion is defended on the grounds that a majority supports a woman's right to choose abortion. The author of this response asserts that abortion can be defended because human fetuses are not persons and because religious commitments cannot be enforced in a pluralistic society. Furthermore, even infants who have severe anomalies need not be treated as potential persons. While a woman has no moral right to the death of her fetus, she does have the right to the safest surgical procedure and to a consideration of the short-term welfare of the fetus or the long-term welfare of children who may result from rescued fetuses. In each case, the denial of life may be the only way to minimize suffering. Even healthy fetuses can be aborted using this procedure on these grounds. Every child should be a wanted child, and until our society learns to care about the reality of a child instead of merely the idea, we have a duty to ensure a stillborn in any late abortion. While basing moral arguments on society's moral failures places ethicists in an uncomfortable position, it is harder to ignore the realities of life that suggest that children should be born only to those prepared to accommodate them.

Rowland is a social scientist and a radical feminist, and she has undertaken the task of making readers think twice about reproductive technologies. If a reader isn't thinking twice, it will not do to blame it on Rowland and the shortcomings of her book. She has a good deal to say that is extremely important and that needs to be considered by anyone who is interested in the moral issues, in general, and the issues for women and children, in particular, that are raised by the new and emerging reproductive technologies. Her book should be widely read. And it should generate the worries it is written to generate.

Observational and experimental data suggest that antioxidant and/or zinc supplements may delay progression of age-related macular degeneration (AMD) and vision loss.To evaluate the effect of high-dose vitamins C and E, beta carotene, and zinc supplements on AMD progression and visual acuity.The Age-Related Eye Disease Study, an 11-center double-masked clinical trial, enrolled participants in an AMD trial if they had extensive small drusen, intermediate drusen, large drusen, noncentral geographic atrophy, or pigment abnormalities in 1 or both eyes, or advanced AMD or vision loss due to AMD in 1 eye. At least 1 eye had best-corrected visual acuity of 20/32 or better. Participants were randomly assigned to receive daily oral tablets containing: (1) antioxidants (vitamin C, 500 mg; vitamin E, 400 IU; and beta carotene, 15 mg); (2) zinc, 80 mg, as zinc oxide and copper, 2 mg, as cupric oxide; (3) antioxidants plus zinc; or (4) placebo.(1) Photographic assessment of progression to or treatment for advanced AMD and (2) at least moderate visual acuity loss from baseline (or =15 letters). Primary analyses used repeated-measures logistic regression with a significance level of.01, unadjusted for covariates. Serum level measurements, medical histories, and mortality rates were used for safety monitoring.Average follow-up of the 3640 enrolled study participants, aged 55-80 years, was 6.3 years, with 2.4% lost to follow-up. Comparison with placebo demonstrated a statistically significant odds reduction for the development of advanced AMD with antioxidants plus zinc (odds ratio [OR], 0.72; 99% confidence interval [CI], 0.52-0.98). The ORs for zinc alone and antioxidants alone are 0.75 (99% CI, 0.55-1.03) and 0.80 (99% CI, 0.59-1.09), respectively. Participants with extensive small drusen, nonextensive intermediate size drusen, or pigment abnormalities had only a 1.3% 5-year probability of progression to advanced AMD. Odds reduction estimates increased when these 1063 participants were excluded (antioxidants plus zinc: OR, 0.66; 99% CI, 0.47-0.91; zinc: OR, 0.71; 99% CI, 0.52-0.99; antioxidants: OR, 0.76; 99% CI, 0.55-1.05). Both zinc and antioxidants plus zinc significantly reduced the odds of developing advanced AMD in this higher-risk group. The only statistically significant reduction in rates of at least moderate visual acuity loss occurred in persons assigned to receive antioxidants plus zinc (OR, 0.73; 99% CI, 0.54-0.99). No statistically significant serious adverse effect was associated with any of the formulations.Persons older than 55 years should have dilated eye examinations to determine their risk of developing advanced AMD. Those with extensive intermediate size drusen, at least 1 large druse, noncentral geographic atrophy in 1 or both eyes, or advanced AMD or vision loss due to AMD in 1 eye, and without contraindications such as smoking, should consider taking a supplement of antioxidants plus zinc such as that used in this study.

Callahan's paper on paternalism and involuntary psychiatric commitment of adults, with comments by Rebecca Dresser, appeared in the August 1984 issue of the Journal of Medicine and Philosophy (Vol. 9, No. 3). In this brief essay, Callahan responds to Dresser's criticisms, in particular to those directed at Callahan's proposed standards for commitment and at her discussion of the incompetence criterion.

An outbreak of hepatitis type A occurred among military personnel and dependents on a military post in Anchorage, Alaska, August 1976-April 1977. One hundred sixteen clinical cases of hepatitis were identified over a nine-month-period. Ninety-six per cent of those cases that were tested demonstrated IgM antibody to hepatitis A virus. A large child care facility was implicated as a major focus of hepatitis virus transmission. Sixty-four (55%) of the cases were directly or indirectly linked to the child care facility. The length of time that a child spent at the facility appeared to increase the child's risk of developing hepatitis and the risk of his transmitting the hepatitis A virus to other members of the immediate household.

The determination of lead isotope ratios in 14 bullets, and in material taken from 9 hand swabs and 5 primers shows that there are potentially valuable forensic uses for such a method. While a more complete study is required, this method could possibly be used to prove (or disprove) relatiohships between bullets and manufacturers, weapons, or persons firing the weapons. Sample size requirements (1 microgram or less) are such that damaged or fragmented bullets, or minute particles therefrom, may be used for the required analyses. An experiment showed that gunshot residue from a test-fired weapon was detectable even after washing the hands.

My purpose in this paper is to show that current legal criteria for paternalistic involuntary psychiatric confinement of the mentally ill are both too narrow and too broad. I do this by first developing a principle of justified paternalistic interference with adults, which I take to be acceptably protective of individual liberty, but which does not require unnecessary sacrifices of individual welfare. After offering an analysis of current legal criteria for involuntary confinement, I argue that an acceptable theory of paternalistic interference reveals that those criteria (1) exclude some cases where confinement would be morally permissible, and (2) allow paternalistic confinement of many whose detention is not morally justifiable.Callahan develops a principle of justified paternalism for involuntary commitment of the mentally ill which supports a narrower definition of dangerousness, and permits a wider range of self harms to meet the standard of incompetence, than do current legal criteria. She argues that the current criteria exclude some cases where confinement would be morally permissible, while allowing paternalistic confinement of many whose detention is not justifiable.