Risk Factors

Objective: To examine the significance of neonatal risk factors from the individual, family, social, and parenting behavior domains of the ecological model of child maltreatment in predicting maltreatment reports in the first 4 years of life, and to examine the extent to which the interactions of life event stress and social support modify those risk factors. Method: Mothers of 708 predominantly at-risk infants were interviewed in their homes soon after their infants' discharge from the hospital. State child abuse and neglect central registry data were tracked every 6 months until the infants reached their fourth birthdays. Results: The incidence of maltreatment reports was higher in households where the mothers were depressed, complained of psychosomatic symptoms, had not graduated from high school, consumed alcohol, participated in public income support programs, cared for more than one dependent child, or were separated from their own mothers at age 14 years (p Ͻ .1). In interaction models including these seven predisposing variables, there were significant interactions (p Ͻ .01) between social support, as measured by the social well-being index after the birth of the index child, and depression, and between social well-being and stress, as measured by an increase in total life events. Conclusion: Some predisposing risk factors measured soon after birth continue to be significant predictors of child maltreatment reports through the fourth year of life. In general, families with low levels of social support had a higher risk of a maltreatment report. For families with lower levels of maternal depression and/or life event stress, low social support significantly increased the risk of a maltreatment report by as much as a factor of four.

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Background: Guidelines recommend multifactorial intervention programmes to prevent falls in older adults but there are few randomised controlled trials in a real life health care setting. We describe the rationale, intervention, study design, recruitment strategies and baseline characteristics of participants in a randomised controlled trial of a multifactorial falls prevention programme in primary health care.

Choline and betaine are nutrients involved in one-carbon metabolism. Choline is essential for neurodevelopment and brain function. We studied the associations between cognitive function and plasma concentrations of free choline and betaine. In a cross-sectional study, 2195 subjects (55 % women), aged 70-74 years, underwent extensive cognitive testing including the Kendrick Object Learning Test (KOLT), Trail Making Test (part A, TMT-A), modified versions of the Digit Symbol Test (m-DST), Block Design (m-BD), Mini-Mental State Examination (m-MMSE) and Controlled Oral Word Association Test (COWAT). Compared with low concentrations, high choline (.8·4 mmol/l) was associated with better test scores in the TMT-A (56·0 v. 61·5, P¼ 0·004), m-DST (10·5 v. 9·8, P¼ 0·005) and m-MMSE (11·5 v. 11·4, P¼ 0·01). A generalised additive regression model showed a positive dose -response relationship between the m-MMSE and choline (P¼0·012 from a corresponding linear regression model). Betaine was associated with the KOLT, TMT-A and COWAT, but after adjustments for potential confounders, the associations lost significance. Risk ratios (RR) for poor test performance roughly tripled when low choline was combined with either low plasma vitamin B 12 (# 257 pmol/l) concentrations (RR KOLT ¼ 2·6, 95 % CI 1·1, 6·1; RR m-MMSE ¼ 2·7, 95 % CI 1·1, 6·6; RR COWAT ¼ 3·1, 95 % CI 1·4, 7·2) or high methylmalonic acid (MMA) ($3·95 mmol/l) concentrations (RR m-BD ¼ 2·8, 95 % CI 1·3, 6·1). Low betaine (# 31·1 mmol/l) combined with high MMA was associated with elevated RR on KOLT (RR KOLT ¼ 2·5, 95 % CI 1·0, 6·2). Low plasma free choline concentrations are associated with poor cognitive performance. There were significant interactions between low choline or betaine and low vitamin B 12 or high MMA on cognitive performance.

Objectives: Recent studies have suggested that survival following the Norwood procedure is influenced by anatomy and is worse for patients with hypoplastic left heart syndrome (HLHS), particularly aortic atresia (AA), as compared to other forms of functional single ventricle and systemic outflow tract obstruction. The current study was undertaken to evaluate our recent experience with the Norwood procedure and to evaluate potential predictors of operative and 1-year mortality. Methods: A retrospective study of risk factors for operative and 1-year mortality in 158 patients undergoing the Norwood procedure between January 1, 1998 and June 30, 2001. Results: HLHS was present in 102 patients (70 with AA) and other forms of functional single ventricle with systemic outflow tract obstruction in the remaining 56. Operative survival was 77% (122/158), 78% for patients with HLHS and 75% for patients with other diagnoses. Multivariable analysis identified birth weight (odds ratio (OR) 0.18/kg, 95% confidence limit (CL) 0.08-0.42, P , 0:001), associated cardiac anomalies (OR 4.45, 95% CL 1.50-13.2, P ¼ 0:001), total support time (OR 1.02/min, 95% CL 1.01-1.03, P ¼ 0:004), and extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) support (OR 17.8, 95% CL 4.40-71.0, P , 0:001) as predictors of operative mortality. The anatomic diagnosis (HLHS versus non-HLHS) was not a predictor of mortality, P ¼ 0:6). The Kaplan-Meier survival estimate at 1 year was 66% (95% CL 58-73%) and was not different for patients with HLHS compared to non-HLHS, P ¼ 0:5. For patients who have survived the Norwood procedure, survival to 1 year was 86% (95% CL 78-91%). Presence of an extra-cardiac anomaly or genetic syndrome (OR 2.70, 95% CL 0.98-7.41%, P ¼ 0:05) and presence of an additional cardiac defect (OR 3.99, 95% CL 1.67-9.57, P ¼ 0:002) were predictors of worse survival in the first year of life. Conclusions: The Norwood procedure is currently being applied to a heterogeneous group of patients. Operative and 1-year survival are equivalent for patients with HLHS and those with other cardiac defects. The presence of additional cardiac or extra-cardiac anomalies are predictors of poor outcome. q

... This gap between what we know should be provided and what is provided is the result of a poorly structured health care financing system ... applied in a host of other settings where children are served, including schools, health clin-ics, child welfare agencies, and juvenile courts. ...

Delirium is a serious neuropsychiatric syndrome of acute onset that occurs in approximately one in five general hospital patients and is associated with serious adverse outcomes that include loss of adaptive function, persistent cognitive problems and increased mortality. Recent studies indicate a three-domain model for delirium that includes generalised cognitive impairment, disturbed executive cognition, and disruption of behaviours that are under circadian control such as sleep-wake cycle and motor activity levels. As a consequence, attention has focused upon the possible role of the circadian timing system (CTS) in the pathophysiology of delirium. We explored this possibility by reviewing evidence that (1) many symptoms that occur in delirium are influenced by circadian rhythms, (2) many features of recognised circadian rhythm disorders are similar to characteristic features of delirium, (3) common risk factors for delirium are known to disrupt circadian systems, (4) physiological disturbances of circadian systems have been noted in delirious patients, and (5) positive effects in the treatment of delirium have been demonstrated for melatonin and related agents that influence the circadian timing system. A programme of future studies that can help to clarify the relevance of circadian integrity to delirium is described. Such work can provide a better understanding of the pathophysiology of delirium while also identifying opportunities for more targeted therapeutic efforts.

Prematurely born children are at increased risk for cognitive deficits, but the neurobiological basis of these findings remains poorly understood. Since variations in neural circuitry may influence performance on cognitive tasks, recent investigations have explored the impact of preterm birth on connectivity in the developing brain. Diffusion tensor imaging studies demonstrate widespread alterations in fractional anisotropy, a measure of axonal integrity and microstructural connectivity, throughout the developing preterm brain. Functional connectivity studies report that preterm neonates, children and adolescents exhibit alterations in both resting state and task-based connectivity when compared to term control subjects. Taken together, these data suggest that neurodevelopmental impairment following preterm birth may represent a disease of neural connectivity.

To determine the retailer and community level factors associated with frequent and disproportionate sales of handguns that are later used in violent and firearm related crimes (VFC handguns). Design: Cross sectional. The authors used California records to identify all handguns sold by study subjects during 1996-2000 and federal gun tracing records to determine which of these guns had been recovered by a police agency in the US or elsewhere and traced by 30 September 2003. Subjects and setting: The 421 licensed gun retailers in California selling at least 100 handguns annually during 1996-2000. Main outcome measure: The number of VFC handguns per 1000 gun years of exposure. Differences are expressed as incidence rate ratios (RR) with 95% confidence intervals (CI). Results: Subjects accounted for 11.7% of California retailers with handgun sales, 81.5% of handgun sales, and 85.5% of VFC handguns. Among subjects, the 3426 VFC handguns accounted for 48.0% of all traced handguns and 65.0% of those linked to a specified crime. The median VFC handgun trace rate was 0.5/ 1000 gun years (range 0-8.8). In multivariate analysis, this rate increased substantially for each singlepoint increase in the percentage of proposed sales that were denied because the purchasers were prohibited from owning guns (RR 1.43; 95% CI 1.32 to 1.56), and was increased for pawnbrokers (RR 1.26; 95% CI 1.02 to 1.55). Community level crime rates and sociodemographics had little predictive value. Conclusions: Risk factors, largely determined at the retailer level, exist for frequent and disproportionate sales of handguns that are later used in violent and firearm related crimes. Screening to identify high risk retailers could be undertaken with data that are already available.

Main Outcome Measures: Failure of NOM (f-NOM). Results: A total of 164 patients (42%) were operated on immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). At the end, 64% of patients required surgery. Multivariate analysis identified 2 independent predictors of f-NOM: grade V BSI and the presence of a brain injury. The likelihood of f-NOM was 32% if no predictor was present, 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost 7-fold higher than those with successful NOM (4.7% vs 0.7%; P =.07). Conclusions: Nearly two-thirds of patients with grade IV or V BSI require surgery. A grade V BSI and brain injury predict failure of NOM. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which do not represent severe BSI.

Background Bullying has public health importance. It has been reported that both the victims and perpetrators of bullying are more likely to have suicidal ideation and other suicidal behaviours. Moreover, bullying can be a precursor for school violence and can contribute to poor academic performance. The purpose of the study was to raise awareness on the subject in China. We, therefore conducted an analysis of secondary data to determine the prevalence and correlates of having been bullied among in-school adolescents. Methods The data was taken from the Beijing Global School-Based Health Survey conducted in 2003. A weighted analysis to reduce bias due to differing patterns of non-response was conducted using statistical software (SPSS version 14.0). We conducted a backward logistic regression analysis to determine independent predictors for being bullied. Results Out of a total of 2,348 in-school adolescents who participated in the survey, 20% (23% males, and 17% females) reported h...

Background: Postnatal dexamethasone (DXM) treatment is associated with adverse motor outcome. It is largely unknown as to what extent functional outcome at school age is affected. Aims: Our first aim was to determine motor, cognitive, and behavioural outcome at school age of preterm-born children treated with high-dose DXM for pulmonary problems. Our second aim was to identify DXM-related risk factors for adverse outcome. Study design: In this cohort study, we included 53 very preterm-born children treated with DXM (starting dose 0.5 mg/kg/d) after the first week of life. At the median age of 9 years, we performed a detailed neuropsychological assessment. Results: Compared to the norm population, DXM-treated children scored worse on the Movement-ABC (abnormal fine motor, ball skills and balance: 59%, 47% and 30%, respectively). They more often had total (36%), verbal (32%) and performance IQs (55%) below 85 (P b .001, P = .002, P b .001, respectively). On each of the remaining measures, DXM-treated children scored worse than the norm population, except for verbal long-term memory and verbal recognition memory. DXM-related risk factors were associated with poorer performance. Conclusions: At school age, multiple domains of functional outcome were affected in DXM-treated children. Risk factors related to the use of DXM should be considered as serious potentiaters of adverse outcome in children treated with high-dose DXM. Please cite this article as: Hitzert MM, et al, Functional outcome at school age of preterm-born children treated with high-dose dexamethasone, Early Hum Dev (2014), http://dx.

Background To determine whether waist-to-height ratio correlates with coronary artery disease (CAD) severity better, than the body mass index (BMI) as assessed by coronary angiography in Bangladeshi population. Methods This cross sectional study was done on patients in Department of Cardiology in DMCH and those referred in the cath-lab of the Department of Cardiology for CAG during November 2009 to October 2010 involving 120 patients. They were divided into group-A (with coronary score ≥7) and group-B (coronary score <7) depending on Gensisni score. Result There were no statistically significant difference regarding the distribution of age, sex and clinical diagnosis and parameters between the two groups. The mean age of patients was 51.7 ± 8.2 years and 48.8 ± 9.1 years in Group A and Group B respectively with a male predominance in both the groups. Patients in group A had higher BMI ≥25 and waist to height ratio (≥0.55) than Group B which showed a statistically significant asso...

Removal of colorectal adenomas during colonoscopy reduces the incidence of colorectal carcinoma (CRC) and CRC-related mortality [1 -4]. Despite surveillance of patients after resection of adenomas [5] the risk of developing CRC remains higher than in the general population [6]. Moreover, it is known that CRC can be detected in the interval between scheduled surveillance colonoscopies [7]. One of the important causes for interval carcinomas is incomplete removal of the original adenoma [8 -10]. As residual adenomatous tissue has been shown to be capable of rapid regeneration , incomplete resection may result in local recurrence . Several studies have indicated that incomplete removal contributes to a higher subsequent incidence of CRC [5, 9, 14 -16].

Compares conceptualizations of homelessness as a temporary state through which people pass or a permanent trait that emanates from individual characteristics. Evidence from a longitudinal study of 564 homeless families in New York City and additional secondary sources supports the view that for families, homelessness is a temporary state that is resolved by the provision of subsidized housing. Even for single individuals with severe mental disturbances, housing is a key factor in ending homelessness, although here there is more evidence that social services also contribute. Policy implications are that governments should take a more active role in reducing homelessness by providing access to subsidized housing.

Dyssomnias Sleep duration Early childhood Risk factors Consequences Model s u m m a r y Dyssomnias are largely under-diagnosed in infants and toddlers. This literature review proposes an integrative model based on empirical data on determinants and consequences of sleep disturbances occurring in early life. This model proposes that parental behaviors that impede the child's autonomy toward sleep periods are primary grounds for the development of dyssomnias, e.g., parental presence until the child falls asleep, and putting an already sleeping child to bed. The model also indicates the serious potential consequences of a modest but chronic loss of sleep in childhood. At least three developmental domains could be directly affected: behavioral/social competence, cognitive performance, and physical condition. Thus, children with short nocturnal sleep duration before age 3.5 years show increased risk of high hyperactivity-impulsivity scores and low cognitive performance at 6 years compared to children who sleep 11 h per night, after controlling for potentially confounding variables. Moreover, persistent short sleep duration in early infancy increased the risk of suffering of obesity at 6 years of age, after controlling for potentially confounding variables. Finally, the importance of allowing the child to sleep at least 10 h per night in early childhood is stressed, as the National Sleep Foundation Poll suggests, for optimal child development.

OBJECTIVE: To assess the impact of laser peripheral iridotomy (LPI) on forward-scatter of light and subjective visual symptoms and to identify LPI parameters influencing these phenomena. DESIGN: Cohort study derived from a randomized trial, using an external control group. PARTICIPANTS: Chinese subjects initially aged 50 or older and 70 years or younger with bilateral narrow angles undergoing LPI in 1 eye selected at random, and age- and gender-matched controls. METHODS: Eighteen months after laser, LPI-treated subjects underwent digital iris photography and photogrammetry to characterize the size and location of the LPI, Lens Opacity Classification System III cataract grading, and measurement of retinal straylight (C-Quant; OCULUS, Wetzlar, Germany) in the treated and untreated eyes and completed a visual symptoms questionnaire. Controls answered the questionnaire and underwent straylight measurement and (in a random one-sixth sample) cataract grading. MAIN OUTCOME MEASURES: Retina...

Treatment with anti-resorptive agents over 13 months was associated with for three to fivefold lower bone mineral density changes and 1.5-fold increased risk of incidence fracture in vitamin D insufficient as compared to vitamin D repleted postmenopausal osteoporotic women. Introduction Several drugs were registered for the treatment of osteoporosis on the basis of clinical trials in which vitamin D repletion was a pre-requisite inclusion criteria and vitamin D supplements were used as adjunctive therapy. However, in routine clinical practice these supplements are not consistently recommended. Methods We studied 1515 women with postmenopausal osteoporosis under treatment with anti-resorbing agents (alendronate, risedronate, raloxifene) for 13.1 months with an adherence > 75%. The patients were classified as vitamin D deficient (N=514) or vitamin D repleted (N=1001) according to risk factors (N=1062) or the level of 25(OH) vitamin D [25(OH)D] above or below 50 nmol/l (N=453). Results Vitamin D deficient and vitamin D repleted subjects differed significantly for annualized spine and hip bone mineral density (BMD) changes adjusted for all available confounding factors (type of treatment, age, global calcium intake, baseline BMD values). One hundred fifty one patients suffered from a new incident clinical fracture. The adjusted odds ratio for incident fractures in vitamin D deficient as compared to vitamin D repleted women was 1.77 (1.20 -2.59, 95% CI; p=0.004). Conclusions Optimal vitamin D repletion seems to be necessary to maximize the response to anti-resorbers in terms of both BMD changes and anti-fracture efficacy.

Background Rickets affects young infants and toddlers. However, there is a paucity of literature regarding the types of fractures that occur in rachitic patients. Objective To evaluate the age of patients at which radiographically evident rickets occurs, and to characterize the age incidence and fractures that are observed in infants and toddlers with radiographically evident rickets. Materials and methods A retrospective study of children younger than 24 months was performed. Clinical data and radiographs were reviewed. Radiographs obtained within 1 month of the diagnosis were evaluated for the presence or absence of osteopenia, presence or absence of fraying–cupping, and presence and characterization of fractures. Results After exclusion criteria were applied, 45 children were included in the study. Children with rickets evident by radiograph were in the age range of 2–24 months. Fractures were present in 17.5% of the study group, exclusively in mobile infants and toddlers. Fracture types included transverse long bone fractures, anterior and anterior-lateral rib fractures, and metaphyseal fractures. All fractures occurred exclusively in patients with severe, overtly evident rickets. Conclusion Fractures occur in older infants and toddlers with overt rickets and can be seen by radiograph. Fractures do not resemble high-risk non-accidental trauma fractures.

With regard to THC (Δ 9 -tetrahydrocannabinol), the main psychoactive constituent identified in the plant Cannabis sativa L, several facts are indisputable. Cannabis remains the most commonly used drug in the UK among those who reported driving under the influence of illegal drugs in the previous 12 months. There is a significant dose-related decrement in driving performance following cannabis use; raised blood THC concentrations are significantly associated with increased traffic crash and death risk. When cannabis and alcohol are detected together, there is a greater risk to road safety than when either drug is used alone. Patterns of use are important when interpreting blood concentration data: Smoking infrequently a single cannabis cigarette leads to peak plasma THC concentrations (21-267 μg/L) causing acute intoxication. In habitual, daily users, plasma THC concentrations range from 1.0 to 11.0 μg/L and are maintained by sequestration of the drug from the tissues. These facts undoubtedly make setting thresholds for drug-driving legislation difficult but there is clearly a case for cannabis. Determining minimum blood THC concentrations at which a driver becomes sufficiently impaired to be unable to safely drive a vehicle is of particular concern given the increasing medicinal use of the drug. Internationally legislation for driving under the influence of drugs (DUID) is based on either a proof of impairment or a per se approach. For the latter this can be either zerotolerance or based on concentration limits such as those used for alcohol. The different approaches are considered against current scientific evidence.

A quality of care debate centers on whether pressure ulcers result from factors largely dependent on caregivers, or whether pressure ulcers result from factors associated with patient morbidity. A reduction in incidence, defined as the development of a new pressure ulcer, is the focus of prevention strategies. Yet epidemiological data demonstrates a stability in the incidence of pressure ulcers despite drastic improvements in understanding of pressure ulcers, increased regulatory oversight, and improvements in technologies available for prevention of pressure ulcers. The explanation for this stable incidence of pressure ulcers includes a failure of known effective preventive treat-ment to be applied or the failure of prevention strategies to be effective in spite of being applied. No intervention strategy has been reported that consistently and reproducibly reduces the incidence of pressure ulcers to zero. The published data on prevention of pressure ulcers do not support an assumption that all pressure ulcers are preventable. An effective prevention strategy demonstrated to eliminate pressure ulcers across healthcare settings is lacking. (J Am Med Dir Assoc 2003; 4: S44-S48)

Hypertension is one of the most important cardiovascular (CV) risk factor, and that lowering blood pressure levels reduces the incidence of CV morbidity and mortality. The higher incidence of hypertension in postmenopausal than in pre-menopausal women raises the attention on the pathophysiological mechanisms potentially involved in post-menopausal ones and outweigh those involved in pre-menopausal women. However, CV disease is one of the leading causes of death in reproductive-age women. Thus, improved awareness, early identification and prompt clinical management of hypertension should be key elements in order to prevent hypertension-related CV morbidity and mortality in pre-menopausal women. However, available data in this specific age group of women are relatively poor and inconsistent, so that the clinical management of young hypertensive women is still debated. The aim of this review is to assess whether there are clear evidences on differences between men and women in epidemiological data, pathophysiological mechanisms, diagnostic options and therapeutic interventions of hypertension and its prognosis, in order to establish the correct approach to this group of hypertensive patients.

The beneficial effect of exercise training and exercise-based cardiac rehabilitation on symptom-free exercise capacity,cardiovascular and skeletal muscle function, quality of life, general healthy lifestyle, and reduction of depressive symptoms and psychosocial stress is nowadays well recognized. However, it remains largely obscure, which characteristics of physical activity (PA) and exercise training--frequency, intensity, time (duration), type (mode), and volume (dose: intensity x duration) of exercise--are the most effective. The present paper, therefore, will deal with these exercise characteristics in the management of individuals with cardiovascular disease, i.e. coronary artery disease and chronic heart failure patients, but also in patients with congenital or valvular heart disease. Based on the current literature, and if sufficient evidence is available, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding fr...

Background  Extremely low and very low gestational age (ELGA and VLGA) constitutes a risk factor for development even in absence of cerebral damage, as an immature central nervous system is exposed to invasive and inadequate stimulation. We tested the hypothesis that GA impacts developmental outcomes and trajectories of preterms without major cerebral damage in the first 2 years of life, expecting poorer developmental outcomes and higher rate of impairment with the decreasing of GA. We also evaluated whether GA, together with developmental outcomes in the first year of life, was related to developmental outcomes at 24 months.Methods  Eighty-eight infants, divided into three GA groups (ELGA: ≤28 weeks; VLGA: 29–32 weeks; full term: >37 weeks) were assessed longitudinally at 6, 12, 18 and 24 months using the Griffiths Mental Development Scales.Results  Use of a repeated measure multivariate analysis of variance resulted in several significant findings. GA was associated with the developmental quotient (DQ) scores (P= 0.006); and locomotor (P < 0.001), eye and hand co-ordination (P= 0.016) and performance (P= 0.040) sub-scale quotient (SQ) scores; age of evaluation was also associated with DQ scores (P= 0.002), and locomotor (P < 0.001) and performance (P < 0.001) SQ scores. In particular, ELGAs exhibited lower DQ and SQ scores compared with the VLGA and full-term groups; some ELGAs showed mild, moderate or severe cognitive impairments, while few VLGAs mild impairments. Linear regression analysis showed that GA (P= 0.034) and 12-month developmental outcome (P < 0.001) were related to 24-month developmental outcome.Conclusions  Different developmental trajectories emerged in relation to GA, with poorer developmental outcomes and higher rates of impairment in ELGAs and few mild impairments in VLGAs. The relevance of taking into account both GA and repeated assessments in the first 2 years of life was shown.

Family environmental factors and parenting styles can be major determinants of obesity risk in children. 1-4 According to the Centers for Disease Control and Prevention, in 2012, 18% of children (aged 6-11 years) were obese, and 21% of adolescents (aged 12-19 years) were obese in the United States. 5 In Arabic-speaking countries, the prevalence of obesity in children and adolescents ranges from 5% to 14% in males and from 3% to 18% in females. 6 However, there is a lack of accurate and comprehensive data on the extent of the problem of obesity among Arab children. 7 To prevent obesity in Arab children, there is a need for research on parenting styles and family factors contributing to obesity so that nutrition education programs can be developed to address these factors. The validat

Cardiovascular risk is poorly managed in women, especially during the menopausal transition when susceptibility to cardiovascular events increases. Clear gender differences exist in the epidemiology, symptoms, diagnosis, progression, prognosis, and management of cardiovascular risk. Key risk factors that need to be controlled in the peri-menopausal woman are hypertension, dyslipidaemia, obesity, and other components of the metabolic syndrome, with the avoidance and careful control of diabetes. Hypertension is a particularly powerful risk factor and lowering of blood pressure is pivotal. Hormone replacement therapy is acknowledged as the gold standard for the alleviation of the distressing vasomotor symptoms of the menopause, but the findings of the Women's Health Initiative (WHI) study generated concern for the detrimental effect on cardiovascular events. Thus, hormone replacement therapy cannot be recommended for the prevention of cardiovascular disease. Whether the findings of WHI in older post-menopausal women can be applied to younger peri-menopausal women is unknown. It is increasingly recognized that hormone therapy is inappropriate for older post-menopausal women no longer displaying menopausal symptoms. Both gynaecologists and cardiovascular physicians have an important role to play in identifying peri-menopausal women at risk of cardiovascular morbidity and mortality and should work as a team to identify and manage risk factors such as hypertension.

n engl j med 360;5 nejm.org january 29, 2009 538 Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal 1. influenza immunization in mothers and infants. N Engl J Med 2008;359:1555-64. Ali HM, Scott R, Toms GL. The effect of foster feeding and 2. bottle feeding expressed breast-milk on the susceptibility of guinea-pig infants to influenza virus. Br J Exp Pathol 1989;70: 183-91. Chantry CJ, Howard CR, Auinger P. Full breastfeeding dura3. tion and associated decrease in respiratory tract infection in US children. Pediatrics 2006;117:425-32.

Background: International youth holiday resorts feature many of the key risk factors for violence, including large numbers of bars and nightclubs and high levels of substance use. However, little information currently exists on the extent of violence amongst holidaymakers or factors that increase risks of involvement in fights on holiday. Methods: A cross-sectional comparative survey of 3003 British, German and Spanish holidaymakers aged 16-35 years, undertaken in the departure areas of Ibiza and Majorca (Spain) airports. Results: Nightlife was the most common reason for destination choice in both locations. Overall, more than half of participants reported drinking to drunkenness at least 2 days per week during their holiday (59.3% Majorca, 58.0% Ibiza; significantly lower in Spanish participants in both locations). Levels of illicit drug use were highest in Ibiza and in British and Spanish holidaymakers. Levels of violence were highest in Majorca, where 6.4% of participants reported involvement in a fight, compared with 2.8% in Ibiza. However, after controlling for confounding factors, holiday destination was not a significant predictor of violence. Predictors of fighting were being male, young, British, frequent drunkenness and use of cannabis or cocaine during the holiday. Use of ecstasy on holiday was associated with not being involved in violence. Conclusions: High levels of substance use contribute to violence being a relatively common feature of young people's visits to international holiday resorts. To protect the health and well-being of holidaymakers and local populations in popular resorts, violence and substance use prevention must adapt to an increasingly globalized nightlife.

In Europe, laryngeal cancer accounts for only 2 Á/5% of all cancers, the incidence being much higher among males than among females. Smoke and alcohol represent the major behavioural risk factors. Several carcinogens, occupations and vitamin deficiencies have been associated with laryngeal cancer. A genetic susceptibility to environmental risk factors and carcinogens is recognized. Hoarseness is the main symptom for which patients call for medical consultation. Mucosa is the most common histologic site of the primary lesions considered in the present chapter. Nodal involvement, the site and volume of the primary tumour, and some genes expression represent the major prognostic factors. A high death rate for not cancer-related events is to be pointed out. The locoregional extent of the disease determines the success of cure. Surgery and radiotherapy represent the main therapeutic options. The choice between these two procedures is often controversial. #

This article reviews the state-of-the-art research in posttraumatic stress disorder (PTSD) from several perspectives: (1) Sex differences: PTSD is more frequent among women, who tend to have different types of precipitating traumas and higher rates of comorbid panic disorder and agoraphobia than do men. (2) Risk and resilience: The presence of Group C symptoms after exposure to a disaster or act of terrorism may predict the development of PTSD as well as comorbid diagnoses. (3) Impact of trauma in early life: Persistent increases in CRF concentration are associated with early life trauma and PTSD, and may be reversed with paroxetine treatment. (4) Imaging studies: Intriguing findings in treated and untreated depressed patients may serve as a paradigm of failed brain adaptation to chronic emotional stress and anxiety disorders. (5) Neural circuits and memory: Hippocampal volume appears to be selectively decreased and hippocampal function impaired among PTSD patients. (6) Cognitive behavioral approaches: Prolonged exposure therapy, a readily disseminated treatment modality, is effective in modifying the negative cognitions that are frequent among PTSD patients. In the future, it would be useful to assess the validity of the PTSD construct, elucidate genetic and experiential contributing factors (and their complex interrelationships), clarify the mechanisms of action for different treatments used in PTSD, discover ways to predict which treatments (or treatment combinations) will be successful for a given individual, develop an operational definition of remission in PTSD, and explore ways to disseminate effective evidence-based treatments for this condition.