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Background: Health promotion and growth-based interventions can effectively improve individual well-being; however, significant gaps in access and utilization still exist., Objective: This study aims to develop and test the effectiveness and implementation of a new, widely targeted conversational agent prevention program (Zenny) designed to enhance well-being., Methods: A total of 1345 individuals in the United States were recruited online and randomly assigned to either (1) a self-help program intervention delivered via an automated conversational agent on WhatsApp or (2) an active control group that had access to evidence-based wellness resources available online. The primary outcomes were well-being (measured using the 5-item World Health Organization Well-being Scale), psychosocial flourishing (assessed with the Flourishing Scale), and positive psychological health (evaluated with the Mental Health Continuum-Short Form). Outcome measures were collected at baseline and again 1 month postassessment. All analyses were conducted using an intention-to-treat approach., Results: Both groups showed significant improvements in well-being (self-help program intervention group effect size: Cohen d=0.26, P<.001; active control group effect size: d=0.24, P<.001), psychosocial flourishing (intervention: d=0.19, P<.001; active control: d=0.18, P<.001), and positive psychological health (intervention: d=0.17, P=.001; active control: d=0.24, P<.001) at postassessment. However, there were no significant differences in effectiveness between the 2 groups (P ranged from .56 to .92). As hypothesized a priori, a greater number of days spent actively engaging with the conversational agent was associated with larger improvements in well-being at postassessment among participants in the intervention group (β=.109, P=.04)., Conclusions: The findings from this study suggest that the free conversational agent wellness self-help program was as effective as evidence-based web resources. Further research should explore strategies to increase participant engagement over time, as only a portion of participants were actively involved, and higher engagement was linked to greater improvements in well-being. Long-term follow-up studies are also necessary to assess whether these effects remain stable over time., Trial Registration: ClinicalTrials.gov NCT06208566; https://clinicaltrials.gov/ct2/show/NCT06208566; OSF Registries osf.io/ahe2r; https://doi.org/10.17605/osf.io/ahe2r., (©Heather M Foran, Christian Kubb, Janina Mueller, Spencer Poff, Megan Ung, Margaret Li, Eric Michael Smith, Akinniyi Akinyemi, Melanie Kambadur, Franziska Waller, Mario Graf, Y-Lan Boureau. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.12.2024.)

The Stroke Treatment Academic Industry Roundtable (STAIR) convened a session and workshop regarding enrollment in acute stroke trials during the STAIR XII meeting on March 22, 2023. This forum brought together stroke physicians and researchers, members of the National Institute of Neurological Disorders and Stroke, industry representatives, and members of the US Food and Drug Administration to discuss the current status and opportunities for improving enrollment in acute stroke trials. The workshop identified the most relevant issues impacting enrollment in acute stroke trials and addressed potential action items for each. Focus areas included emergency consent in the United States and other countries; careful consideration of eligibility criteria to maximize enrollment and representativeness; investigator, study coordinator, and pharmacist availability outside of business hours; trial enthusiasm/equipoise; site start-up including contractual issues; site champions; incorporation of study procedures into standard workflow as much as possible; centralized enrollment at remote sites by study teams using telemedicine; global trials; and coenrollment in trials when feasible. In conclusion, enrollment of participants is the lifeblood of acute stroke trials and is the rate-limiting step for testing an exciting array of new approaches to improve patient outcomes. In particular, efforts should be undertaken to broaden the medical community's understanding and implementation of emergency consent procedures and to adopt designs and processes that are easily incorporated into standard workflow and that improve trials' efficiencies and execution. Research and actions to improve enrollment in ongoing and future trials will improve stroke outcomes more broadly than any single therapy under consideration., Competing Interests: Disclosures Dr Broderick receives monies from National Institute of Neurological Disorders and Stroke (NINDS) for research grants, receives study medication and monies for temperature monitoring and after-business hour enrollments from Novo Nordisk for NINDS-funded FASTEST Trial (rFVIIa for Acute Hemorrhagic Stroke Administered at Earliest Time Trial). The Department of Neurology receives monies to an educational/research fund from Genentech for his role on Executive Committee of Timeless Trial; from Roche Pharmaceuticals for consulting, from BrainsGate Ltd for consulting; from Basking Biosciences, from Kroger Prescription Plans Inc’s Pharmacy &Therapeutics Committee as voting member of committee. Dr Silva reports funding from the Brazilian Ministry of Health for the Resilient and OPTIMAL trials; consulting and speaker fees from AstraZeneca, Biogen, Boehringer Ingelheim, and Pfizer; consulting fees from IschemaView and Bayer, and speaker fees from Abbott. Dr Selim receives grant funding from the NINDS and NIA (related to and outside of the current work), and royalties from Up to Date and Cambridge University Press and is on the Advisory Board of MedRhythms Inc. Dr Kasner has received grant funding (to institution) from Genentech, Diamedica, Bristol-Myers Squibb, Bayer, Stryker, and Medtronic; consulting fees from Shionogi, Abbvie, Artivion, AstraZeneca, and NeuExcell; and royalties from UpToDate and Elsevier. Dr Adeoye receives funding from NINDS and has equity in and is the Chief Medical Officer for Sense Diagnostics, Inc and receives compensation from NICO Corporation for data and safety monitoring services. Dr Hill reports grants from MicroVention Inc; employment by University of Calgary; grants from Medtronic; grants from Boehringer Ingelheim; grants from Medtronic; grants from Medtronic; grants from Canadian Institutes of Health Research; grants from Biogen Inc; compensation from Brainsgate Ltd for consultant services; and grants from NoNO Inc. Dr Mistry receives funding from National Institutes of Health/NINDS and Patient-Centered Outcomes Research Institute (PCORI) and receives monies for consulting for RAPID AI, Abbvie, and the American Heart Association. Dr Smith is an employee of AbbVie Inc, and holds AbbVie stock and stock options. All inputs to this article are based on personal experiences and opinions, and do not necessarily reflect AbbVie’s views. J. Sutherland is the Clinical Operations Manager for Revalesio. Dr Lyden receives royalty Income for “Thrombolytic Therapy for Acute Stroke” Third Edition Springer Press, is the PI for NINDS grants U24 NS13006000 and UG3 NS119199, and monies for consulting for Apex Innovations. Dr Jauch receives monies for consulting for RapidAI, and reports compensation from Schultz & Pogue, LLP, and McLeod Law Group for expert witness services. Dr Hernandez-Jimenez works for aptaTargets Dr Mocco receives grant funding from Stryker Neurovascular, Penumbra, and Microvention, as well as a research award from PCORI. Dr Mocco reports stock holdings in Endostream; stock holdings in Viz.ai; stock options in Neuroradial Technologies; stock options in Echovate; compensation from CVAid for consultant services; compensation from Penumbra Inc for other services; stock options in Whisper; compensation from RIST Neurovascular, Inc, for consultant services; stock options in Neurotechnology Investors, LLC, Managers; stock holdings in Q’Apel; grants from PCORI; compensation from Stryker for other services; compensation from MicroVention Inc for other services; stock holdings in Vastrax; stock holdings in Imperative Care Inc; compensation from Synchron for consultant services; stock holdings in Blinktbi; stock holdings in Cerebrotech; stock options in Sim&Cure; stock holdings in Spinaker; stock options in Spinaker; compensation from CVAid for consultant services; stock options in Songbird; stock options in E8; compensation from Perflow for consultant services; employment by Mount Sinai Health System; stock options in Tulavi; stock options in Borvo; stock holdings in Viseon Inc; stock options in Radical; and stock options in Neurolutions. E. Deljkich is Vice President, Clinical Affairs, Imperative Care. Dr Kamel is the PI for the ARCADIA trial (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke; NIH/NINDS U01NS095869), which received in-kind study drug from the BMS-Pfizer Alliance for Eliquis and ancillary study support from Roche Diagnostics; other funding from NIH (R01HL144541, R01NS123576, and U01NS106513); Deputy Editor for JAMA Neurology; clinical trial steering/executive committees for Medtronic, Janssen, and Javelin Medical; end point adjudication committees for AstraZeneca, Novo Nordisk, and Boehringer Ingelheim; and household ownership interests in TETMedical, Spectrum Plastics Group, and Burke Porter Group.

Upon request from tribal nations, and as part of the Centers for Disease Control and Prevention's (CDC's) emergency response, CDC staff provided both remote and on-site assistance to tribes to plan, prepare, and respond to the COVID-19 pandemic. From April 2, 2020, through June 11, 2021, CDC deployed a total of 275 staff to assist 29 tribal nations. CDC staff typically collaborated in multiple work areas including epidemiology and surveillance (86%), contact tracing (76%), infection prevention control (72%), community mitigation (72%), health communication (66%), incident command structure (55%), emergency preparedness (38%), and worker safety (31%). We describe the activities of CDC staff in collaboration with 4 tribal nations, Northern Cheyenne, Hoopa Valley, Shoshone-Bannock, and Oglala Sioux Tribe, to combat COVID-19 and lessons learned from the engagement.

Retractions of coronavirus disease 2019 (COVID-19) papers in high impact journals, such as The Lancet and the New England Journal of Medicine, have been panned as major scientific fraud in public media. The initial reaction to this news was to seek out scapegoats and blame individual authors, peer-reviewers, editors, and journals for wrong doing. This paper suggests that scapegoating a few individuals for faulty science is a myopic approach to the more profound problem with peer-review. Peer-review in its current limited form cannot be expected to adequately address the scope and complexity of large interdisciplinary science research collaboration, which is central in translational research. In addition, empirical studies on the effectiveness of traditional peer-review reveal its very real potential for bias and groupthink; as such, expectations regarding the capacity and effectiveness of the current peer review process are unrealistic. This paper proposes a new vision of peer-review in translational science that, on the one hand, would allow for early release of a manuscript to ensure expediency, whereas also creating a forum or a collective of various experts to actively comment, scrutinize, and even build on the research under review. The aim would be to not only generate open discussion and oversight respecting the quality and limitations of the research, but also to assess the extent and the means for that knowledge to translate into social benefit., (© 2021 The Authors. Clinical and Translational Science published by Wiley Periodicals LLC on behalf of the American Society for Clinical Pharmacology and Therapeutics.)

Childhood obesity is an epidemic in the US. This article discusses the evolution, prevention, and associated physical and psychosocial consequences of and interventions for obesity in the pediatric population.

Various U.S. laws, such as the Clean Air Act and the Food Quality Protection Act, require additional protections for susceptible subpopulations who face greater environmental health risks. The main ethical rationale for providing these protections is to ensure that environmental health risks are distributed fairly. In this article, we (1) consider how several influential theories of justice deal with issues related to the distribution of environmental health risks; (2) show that these theories often fail to provide specific guidance concerning policy choices; and (3) argue that an approach to public decision making known as accountability for reasonableness can complement theories of justice in establishing acceptable environmental health risks for the general population and susceptible subpopulations. Since accountability for reasonableness focuses on the fairness of the decision-making process, not the outcome, it does not guarantee that susceptible subpopulations will receive a maximum level of protection, regardless of costs or other morally relevant considerations.

One of the most significant changes to the Common Rule is the requirement that institutions use a single Institutional Review Board (IRB) for cooperative research in the United States, unless more than one IRB is required by state, local, or tribal law, or a signatory federal agency decides an exception is warranted. We surveyed Human Research Protection Program (HRPP) officials at the top U.S. research institutions to understand their knowledge and opinion of the mandate, what steps their institutions are taking, and difficulties their institutions are facing. One-hundred seven institutions (56.9%) responded to the survey. While support for the single-IRB mandate was positive overall, most respondents acknowledged that their institution is likely to face some difficulties complying with it. Regulatory agencies can help institutions to comply with the mandate by providing guidance concerning such issues as exceptions to the mandate, local context review, oversight, and implementation of reliance agreements, and development of policies, procedures, and best practices.

Because numerous barriers hinder the assessment and management of chemotherapy-induced peripheral neuropathy in clinical practice, the Carevive Care Planning System, a novel Web-based platform, was developed to address these barriers. It provides patients an opportunity to report their symptoms before their clinic visit and generates customizable care plans composed of evidence-based management strategies. The purpose of this study was to evaluate patient and provider perspectives of feasibility, usability, acceptability, and satisfaction with the Carevive platform. We used a single-arm, pretest/posttest, prospective design and recruited 25 women with breast cancer who were receiving neurotoxic chemotherapy and six advanced practice providers from an academic hospital. At three consecutive clinical visits, patients reported their neuropathy symptoms on a tablet via the Carevive system. The Diffusion of Innovations Theory served as an overarching evaluation framework. The Carevive platform was feasible to use. However, patients had higher ratings of usability, acceptability, and satisfaction with the platform than did the providers, who disliked the amount of time required to use the platform and had difficulty logging into Carevive. If issues regarding provider dissatisfaction can be addressed, the Carevive platform may aid in the screening of neuropathy symptoms and facilitate the use of evidence-based management strategies.

Background: Conventional markers of juvenile-onset systemic lupus erythematosus (JSLE) disease activity fail to adequately identify lupus nephritis (LN). While individual novel urine biomarkers are good at detecting LN flares, biomarker panels may improve diagnostic accuracy. The aim of this study was to assess the performance of a biomarker panel to identify active LN in two international JSLE cohorts., Methods: Novel urinary biomarkers, namely vascular cell adhesion molecule-1 (VCAM-1), monocyte chemoattractant protein 1 (MCP-1), lipocalin-like prostaglandin D synthase (LPGDS), transferrin (TF), ceruloplasmin, alpha-1-acid glycoprotein (AGP) and neutrophil gelatinase-associated lipocalin (NGAL), were quantified in a cross-sectional study that included participants of the UK JSLE Cohort Study (Cohort 1) and validated within the Einstein Lupus Cohort (Cohort 2). Binary logistic regression modelling and receiver operating characteristic curve analysis [area under the curve (AUC)] were used to identify and assess combinations of biomarkers for diagnostic accuracy., Results: A total of 91 JSLE patients were recruited across both cohorts, of whom 31 (34 %) had active LN and 60 (66 %) had no LN. Urinary AGP, ceruloplasmin, VCAM-1, MCP-1 and LPGDS levels were significantly higher in those patients with active LN than in non-LN patients [all corrected p values (p c ) < 0.05] across both cohorts. Urinary TF also differed between patient groups in Cohort 2 (p c  = 0.001). Within Cohort 1, the optimal biomarker panel included AGP, ceruloplasmin, LPGDS and TF (AUC 0.920 for active LN identification). These results were validated in Cohort 2, with the same markers resulting in the optimal urine biomarker panel (AUC 0.991)., Conclusion: In two international JSLE cohorts, urinary AGP, ceruloplasmin, LPGDS and TF demonstrate an 'excellent' ability for accurately identifying active LN in children., Competing Interests: Compliance with ethical standards All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Patient assent/consent and parental consent was obtained to participate in the studies. Full ethical approvals were in place from the National Research Ethics Service North West, Liverpool East, UK (reference 06/Q1502/77) and the Institutional Review Board at Einstein-Montefiore (IRB 2000–154). Conflicts of interest There has not been any financial support or other benefits from commercial sources for the work reported on in this manuscript. The authors do not have any financial interests that could create a potential conflict of interest or the appearance of a conflict of interest with regard to the work. Funding This work was supported by the Alder Hey Children’s Kidney Fund through a training fellowship [UOG10065 to ES]. Lupus UK also provides financial support for co-ordination of the UK JSLE Cohort Study. TR is supported by the Lupus Foundation of America Career Development Award, and the NIH (National Institutes of Health) Loan Repayment Program for Pediatric Research. BG is supported by the Children’s Hospital at Montefiore Young Investigator Award. CP and BG are supported by NIH/NCI 1U19CA179564 and NIH/NCI 1UH2/3TR000933. The funding bodies detailed above were not involved in the design, collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Vitamin D deficiency is highly prevalent in the US population and is associated with numerous diseases, including those characterised by inflammatory processes. We aimed to investigate the link between vitamin D status and anaemia, hypothesising that lower vitamin D status would be associated with increased odds of anaemia, particularly anaemia with inflammation. A secondary aim was to examine the effects of race in the association between vitamin D status and anaemia. We conducted a cross-sectional analysis in a cohort of generally healthy adults in Atlanta, GA (n 638). Logistic regression was used to evaluate the association between vitamin D status and anaemia. Serum 25-hydroxyvitamin D (25(OH)D) < 50 nmol/l (compared to 25(OH)D ≥ 50 nmol/l) was associated with anaemia in bivariate analysis (OR 2·64, 95% CI 1·43, 4·86). There was significant effect modification by race (P= 0·003), such that blacks with 25(OH)D < 50 nmol/l had increased odds of anaemia (OR 6·42, 95% CI 1·88, 21·99), v. blacks with 25(OH)D ≥ 50 nmol/l, controlling for potential confounders; this association was not apparent in whites. When categorised by subtype of anaemia, blacks with 25(OH)D < 50 nmol/l had significantly increased odds of anaemia with inflammation than blacks with serum 25(OH)D ≥ 50 nmol/l (OR 8·42, 95% CI 1·96, 36·23); there was no association with anaemia without inflammation. In conclusion, serum 25(OH)D < 50 nmol/l was significantly associated with anaemia, particularly anaemia with inflammation, among blacks in a generally healthy adult US cohort.

Background: Vincristine-induced peripheral neuropathy (VIPN) is difficult to quantify in children., Objective: The study objective was to examine the reliability, validity, and clinical feasibility of several VIPN measures for use in children with acute lymphoblastic leukemia., Interventions/methods: Children (n = 65) aged 1 to 18 years receiving vincristine at 4 academic centers participated in the study. Baseline and pre-vincristine administration VIPN assessments were obtained using the Total Neuropathy Score-Pediatric Vincristine (TNS©-PV), the National Cancer Institute Common Terminology Criteria for Adverse Events, the Balis grading scale, and the FACES Pain Scale. The TNS-PV scores (n = 806) were obtained over 15 weeks. Blood was obtained at several time points to quantify pharmacokinetic parameters., Results: Cronbach's α for a reduced TNS-PV scale was .84. The TNS-PV scores correlated with cumulative vincristine dosage (r = 0.53, P = 0.01), pharmacokinetic parameters (r = 0.41, P = 0.05), and grading scale scores (r range = 0.46-0.52, P = .01). FACES scores correlated with the TNS-PV neuropathic pain item (r = 0.48; P = .01) and were attainable in all ages. A 2-item V-Rex score (vibration and reflex items) was the most responsive to change (effect size = 0.65, P < 0.001). The TNS-PV scores were attainable in 95% of children 6 years or older., Conclusions: The TNS-PV is reliable and valid for measuring VIPN. It is sensitive to change over time (15 weeks) and feasible for use in children 6 years or older., Implications for Practice: The TNS-PV may be a useful tool for assessing vincristine toxicity in children with acute lymphoblastic leukemia.

A total of 258 bovine-associated Staphylococcus aureus isolates from the United States, Chile, and the United Kingdom, plus the reference isolate S. aureus Newbould 305 (NCIMB 702892), were analyzed by multilocus sequence typing (MLST). A collection of previously characterized United Kingdom isolates were also included in the analysis. The results demonstrated that MLST is suitable for the differentiation of bovine S. aureus isolates from various sites (milk, teat skin, milking machine unit liners, hands, and bedding) and countries. The theory of the host specificity of S. aureus is supported by the detection of a previously undescribed clonal complex that comprised 87.4% of the isolates studied, with representatives from all geographic locations investigated. This suggests that a single clonal group has achieved a widespread distribution and is responsible for the majority of infections. Some sequence types (STs; ST25, ST115, ST124, and ST126) demonstrated site specificity, as they were significantly (P < 0.05) associated with milk or teat skin.

The storage objectives for the healthcare enterprise (HE) are to ensure that information (images and data) are readily available anywhere and at anytime, images and data are secure, and the storage fulfills legal requirements and the Health Insurance Portability and Accountability Act (HIPAA). These objectives must be satisfied at a minimum economic cost with respect to personnel, hardware, software, space and telecommunications. Many approaches and storage configurations meet these objectives. Which approach is chosen will depend on the size of the institution, patient population, geographic distribution of the institutions (if more than one), type of facility (such as a hospital, outpatient clinic or private imaging center), and financial investment objectives. The quantity of storage required depends on the characteristics of the modalities, the number of imaging devices and databases, the number and location of imaging sites that make up the HE, the size of the data and image, and the projected procedure volume growth. The only certainty with respect to storage requirements is that they will increase significantly with time. The types of storage required in the HE can be described by their functions: Active storage includes both online and long-term storage. Backup images are temporarily backed up on the limited storage capacity of the modality for several days or longer. Additional copies of the study are made on different media (e.g., disk, DVD or tape), in different locations. The process of backing up data and images must be automated. Effective April 21, 2005, HIPAA requires that all healthcare entities have a disaster recovery plan in effect. This requires that a copy of all medical data be secure, retrievable and maintained in a second location, such that if the primary copy of the data is destroyed or made unavailable, the disaster recovery copy would be available. Planning for the HE archive is critical if the HE is to work productively in an integrated digital environment. The information technology department must be an integral part of planning for the HE archive, which must be located in a secure data center and not under the management of any single clinical department. After the technologies currently available are evaluated, it is imperative that the chosen solution is cost-effective and scalable, and that it will allow the HE to take advantage of future storage and storage management technology.

Chronic pain is a debilitating problem for many Americans. It affects physical, social, and emotional health. This study addresses the potential differential effects of chronic pain cross-culturally in younger Americans. A retrospective analysis of persons younger than 50 years of age presenting for chronic pain management in a multidisciplinary pain center was done. White and black American adults aged 18 to 50 years (N = 3669) were compared to determine whether there were differences in (1) psychologic functioning, (2) pain characteristics, (3) pain disability, and (4) comorbidities. Our results suggest that black Americans had more depressive symptoms and symptoms consistent with post-traumatic stress disorder when compared to white Americans. These results showed that on initial assessment, black Americans with chronic pain report significantly more pain and sleep disturbance as well as more symptoms consistent with post-traumatic stress disorder and depression than white Americans. They also experience a higher prevalence of self-identified comorbidities, including dizziness, chest pain, and high blood pressure. In conclusion, considerable diminution in the overall physical and emotional health of black Americans 18 to 50 years of age with chronic pain was noted. These data support the need for further study of the chronic pain experiences of racial and ethnicity minority persons.

In an aging society, chronic pain will increasingly have a significant impact on successful aging. Chronic pain may further differentially affect racial and ethnic minorities while diminishing their health and quality of life. This study addresses the potential differential effects of chronic pain cross-culturally in older Americans. A retrospective analysis of a group of subjects presenting for chronic pain management in a tertiary care multidisciplinary pain center was performed. This comparative study of black and white American adults (N [equals] 2040) was done to determine whether there were differences in (1). psychologic functioning, (2). pain characteristics, (3). pain disability, and (4). comorbidities. The black American population had more depressive symptoms and symptoms of posttraumatic stress disorder when compared with the white Americans. These results suggest that chronic pain adversely affects the quality of life and health status of black Americans to a greater extent than white Americans before initial presentation for treatment at a multidisciplinary pain center. This study of older Americans with chronic pain showed significant differences in pain and health status based on race. It further demonstrates a difference in the chronic pain experience based on race in older Americans.

This report describes a 3-year follow-up study of survivors of a mass shooting incident. Acute-phase and 1-year follow-up data from this incident have been previously reported. The Diagnostic Interview Schedule/Disaster Supplement was used to assess 116 survivors at 1-2 months and again 1 and 3 years later, with an 85% reinterview rate. Examining the course of postdisaster posttraumatic stress disorder (PTSD) and major depression in individuals allowed detailed consideration of remissions and delayed detection of disorders not possible from data presenting overall rates across different time frames. Only about one half of the PTSD cases identified at any time over 3 years were in remission at the 3-year follow-up. Those who did not recover from PTSD diverged from those who recovered at 3 years by reporting increased numbers of symptoms over time, especially avoidance and numbing symptoms. Although women and people with preexisting disorders were at greater risk for the development of PTSD, these variables did not predict chronicity. Chronicity of PTSD was predicted by functional impairment and seeking mental health treatment at baseline. Chronicity of major depression was predicted by report of family history of depression and treatment for paternal alcohol problems. No delayed cases of PTSD were identified. Studies are needed to compare these characteristics of the course of PTSD with other populations, using consistent methodology to allow valid comparison.

Data are presented contrasting racial and ethnic differences in the use of alcohol and other drugs, and in the morbidity and mortality consequent to substance abuse and dependence. In a review of recent studies, whites were found to have higher rates of use, abuse, and dependence than other racial and ethnic groups, despite the common perception that substance abuse is a "minority problem." Epidemiologists are challenged to use appropriate methodologies to study this discrepancy and delineate the roles of both race and racism in addiction.

Recent literature on morbidity and mortality patterns, known risk factors, and related sociobehavioral characteristics of oral cancer have been examined. Despite variation in populations and methodologies, alcohol and tobacco were seen as the major independent etiologic agents; these effects were associated with age, sex, and religion-ethnicity. Other factors were suggested, but their correlation was less consistent: geographic location, race, socioeconomic status, nutrition, dental conditions, and concurrent diseases. Social and behavioral components may alter risk, stage of disease at diagnosis, treatment or survival from oral cancer. The impact of sociobehavioral elements on the reduction of the incidence of and the mortality from the disease is an important area needing further investigation.

We assessed the overall progress against cancer during the years 1950 to 1982. In the United States, these years were associated with increases in the number of deaths from cancer, in the crude cancer-related mortality rate, in the age-adjusted mortality rate, and in both the crude and the age-adjusted incidence rates, whereas reported survival rates (crude and relative) for cancer patients also increased. In our view, the best single measure of progress against cancer is change in the age-adjusted mortality rate associated with all cancers combined in the total population. According to this measure, we are losing the war against cancer, notwithstanding progress against several uncommon forms of the disease, improvements in palliation, and extension of the productive years of life. A shift in research emphasis, from research on treatment to research on prevention, seems necessary if substantial progress against cancer is to be forthcoming.

A telephone survey of 602 randomly selected hospitals was conducted to identify existing ethics committees, i.e., those with the potential to become involved in the decision-making process in specific cases. Using the number of acute care beds as the criterion, hospitals were divided into 2 groups: (1) over 200 beds; n = 400; (2) 200 or fewer beds; n = 202. Chairpersons of identified committees completed detailed questionnaires. Seventeen committees were found--approximately 1% of all U.S. hospitals. A typical committee included physicians, clergymen, and other professionals. Almost all committees were advisory, not decision-making bodies, and considered very effective by their chairpersons. Ethics committees have not, however, solved current medical ethical problems; nor have they allayed the concerns of patients' rights advocates about patient representation and control. Further study is warranted.

The transfer to the Indian Health Service (IHS) of 158 alcohol treatment programs that had been administered by the National Institute on Alcohol Abuse and Alcoholism began in 1978. Today, approximately 300 alcohol and substance abuse treatment programs offer services to American Indians, among them primary residential treatment, halfway houses, outreach, and aftercare. This system provides a national network upon which additional activities may be established. Along with increasing its attention to health promotion and disease prevention, the IHS has moved toward the prevention of alcoholism. A variety of preventive programs are in place that emphasize improved self-image, value and attitude clarification, decision-making, and physical and emotional effects of alcohol and substance abuse. Many begin as Head Start programs and continue through adulthood. In 1986, after consulting with both academic and tribal experts, the IHS devised a strategic plan for alcoholism control that stresses comprehensive care and prevention activities; it serves as a guide for further program development. The Secretary of Health and Human Services created a Task Force on Indian Alcoholism in 1986 to serve as a coordinating body for activities carried out by the IHS and other agencies and units of the Department. Passage of the Anti-Drug Abuse Act in 1986 added resources for the development of adolescent treatment centers and, more importantly, for community-based pre- and post-residential care for youths and their families. Concomitant with these initiatives have been several instances of increased attention by various tribes to the problem of alcoholism. The IHS strategic plan, together with the Secretary's initiative, the Anti-Drug Act, and tribal actions, has added substantial momentum to efforts directed at controlling alcoholism among American Indians. Although the mortality rate from alcoholism is about four times greater for the American Indian population than for the entire U.S. population, it decreased from 54.5 per 100,000 population to 26.1 between 1978 and 1985-a reduction of 52 percent.The philosophy of the IHS in emphasizing prevention of disease and promotion of wellness provides an opportunity for continuing the considerable progress already made. The critical and decisive role played by the Indian communities themselves will determine whether ultimate success can be achieved.

Alcohol and tobacco consumption were compared to rates of tongue cancer mortality among birth cohorts in Japan, England and Wales, and the United States for the years 1846-1975. During 1931-75 Japan had low and the US had high, stable sex, and age-specific and adjusted mortality. Rates in England and Wales, highest among the three nations, dropped dramatically, showing a classic cohort effect, which coincided with a continual rise in tobacco and a sharp decline in alcohol use since 1900. The US had a similar upsurge in smoking, but comparatively little change in drinking habits. In all countries, the alcohol but not the tobacco patterns were consistent with cohort deaths for not only tongue cancer but also other alcohol-related diseases when a dose-response time lapse was taken into account. In contrast to other studies this research suggests that alcohol may be a carcinogen even in the absence of tobacco.