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December 2000

Some Adolescents May Carry a Physiologic Risk for Major Depression 
A specific pattern of psychoendocrine factors appears to predict a subgroup of adolescents who will develop major depression, according to a report published in the December issue of the British Journal of Psychiatry. This risk may be of genetic and/or earlier psychosocial origin, the authors state.
Dr. Ian M. Goodyer and colleagues, from the University of Cambridge, UK, assessed cortisol levels, dehydroepiandrosterone (DHEA) levels, depressive symptoms, life events, and psychiatric disorder at entry and 12 months later in 180 adolescents who met criteria for high risk for psychopathology.
These criteria included "two or more moderately to severely undesirable life events in the previous 12 months; current marital disharmony or past marital breakdown; two or more lifetime exit events (bereavement and/or permanent separation) or personal significance (relative or friend) to the adolescent; and high (>80 percentile) emotionality."
The authors found that 18% of subjects experienced an onset of major depression during the follow-up period. "Major depression was predicted for both genders by the additive effects of: higher depressive symptoms; personal disappointments and losses only in the month before onset; one or more daily levels of cortisol at 8 AM or DHEA at 8 PM greater than the 80th percentile of the daily mean," the researchers state.
"The findings in this paper suggest a putative causal role for cortisol and DHEA that is not a consequence of highly proximal recent life events or subclinical depressive symptoms," they conclude.
SOURCE: Br J Psychiatry 2000;177:499-504.

Most Untreated African HIV Children Will Die by Age 3 
Almost 90% of HIV-infected children in Africa fail to survive until their third birthday. Once an AIDS-related condition occurs, more than half of infected children die within 12 months, according to results of a study conducted in Malawi. Dr. Taha E. Taha, of Johns Hopkins University in Baltimore, Maryland, and colleagues call their study "one of the largest studies of HIV-infected children who have been followed in sub-Saharan Africa."
For about 18 months, the investigators followed 190 HIV-infected children, 499 uninfected children born to HIV-positive mothers, and 119 uninfected children born to HIV-negative mothers. Eighty-nine percent of HIV-infected African children alive at 6 months died by age 3, the authors report in the December issue of Pediatrics. In comparison, in a European study, only 18% of HIV-infected children died by age 3 years, and a US study found that 75% lived to age 5 years, the report indicates.
The researchers suggest that improved management of persistent diarrhea and chronic middle-ear infections would "substantially reduce" deaths in this population. "Efforts to make available simple diagnostic tests and procedures to help clinicians provide better care for the children of developing countries should be a priority," Taha and colleagues conclude.
SOURCE: Pediatrics 2000;106.

Many High School Athletes Use Creatine 
Many high school athletes may be using the purportedly strength-building supplement creatine, often with no idea of what doses they are taking, a new study suggests.
Although a number of studies have shown short-term creatine use to be largely safe in adults, it is unclear whether its possible side effects--like cramps, dehydration and nausea--might be more severe in kids.
Despite this uncertainty, researchers at the Mayo Clinic in Rochester, Minnesota, found that more than 8% of high school athletes in their region have used creatine. Athletes as young as 14 reported using the supplement.
Drs. Jay Smith and Diane L. Dahm report their findings in the December issue of Mayo Clinic Proceedings.
In surveying 328 athletes from five high schools, the researchers found that about 8% had used creatine, most of whom were football players. Most either did not know how much creatine they were taking or were taking more than the recommended dose of 6 to 10 grams a day. The 20% who experienced side effects mainly suffered cramps, diarrhea, or loss of appetite.
A health food store staple, creatine supplements mimic the creatine the body produces naturally to infuse muscle cells with energy. Creatine enthusiasts claim it boosts their strength, and some medical research backs them up.But the supplement does carry side effects. And it remains unclear whether creatine might trigger kidney failure in kids. Because creatine is classified as a dietary supplement, it is not subject to the strict regulation that governs drugs.
While there were no serious side effects reported in this study, Smith and Dahm recommend that larger-scale studies tackle the issue of teenagers' use of creatine. "Essentially," they write, "there are no safety data in the literature regarding creatine use in younger athletes (14-18 years of age), and formal study is necessary."
SOURCE: Mayo Clinic Proceedings 2000;75:1257-1263.

Ecstasy Raises Heart Beat, Blood Pressure 
The increasingly popular "club drug" ecstasy may increase the risk of cardiovascular complications, researchers report.
In a new study, modest doses of the illegal stimulant ecstasy, or MDMA, increased heart rate, blood pressure and the heart's workload as much as a medication used to stimulate the heart. The increases in heart rate and blood pressure are similar to what occurs during vigorous exercise, the study's principal investigator, Dr. John Mendelson, of the University of California at San Francisco, told Reuters Health.
"Although most people, especially young people, should have no problem with this level of increase in heart rate and blood pressure, anyone with ... heart disease could have trouble," he said.
The study included eight people who had used ecstasy at least several times in the past. In the first of four weekly sessions, participants received an increasing intravenous dose of the drug dobutamine, which has heart-stimulating effects. During administration of the medication, patients underwent echocardiography, which produces images of the heart in motion. On three later occasions, the participants received one of two doses of ecstasy or a placebo that did not contain any of the drug.
Heart rate and blood pressure were measured before and after each dose. One hour after receiving the drug or a dummy pill, each person underwent echocardiography.
The higher dose of ecstasy (which corresponds to an average dose of the drug) increased heart rate by about 28 beats per minute, the researchers report in the December 19th issue of the journal Annals of Internal Medicine. And blood pressure also increased, with the upper number (systolic pressure) rising by 25 millimeters of mercury (mm Hg) and the lower number (diastolic pressure) rising by 7 mm Hg. The increases in blood pressure and heart rate were similar to those produced by dobutamine.
The lower dose of ecstasy did not raise blood pressure or heart rate.
When heart rate and blood pressure rise in natural situations, such as while exercising, the heart becomes more efficient by pumping more forcefully, according to Mendelson. But this did not happen when the participants took ecstasy, he pointed out.
"What this means is that the heart is working harder but with less efficiency," Mendelson explained. "This probably decreases the amount of 'cardiac reserve,' meaning that additional demands on cardiac function may not be met." He noted that these changes may not have much of an effect on healthy young people, but in older people or those with undiagnosed heart disease, the effect could be "quite serious."
In the report, Mendelson and his colleagues note that the testing conditions of the study varied a great deal from how ecstasy is usually taken. They point out that many users take the drug while dancing in hot, crowded nightclubs, and they may take more than one dose or drink or take other drugs at the same time. In addition, the effects of the drug may be different in people with cardiovascular disease than in the people in the study, who were all healthy.
In his remarks to Reuters Health, Mendelson commented that physical activity like dancing may compensate for the lack of ecstasy's effect on the heart's efficiency.
SOURCE: Annals of Internal Medicine 2000;133:969-973.

White Youngsters Smoke Cigarettes at Earlier Ages
White smokers in the US say they started their habit at an earlier age than their African-American or Hispanic counterparts, researchers report. The earlier an individual begins smoking, the more likely they are to be a heavy smoker in later adulthood and the less likely they are to try to quit.
The findings are from a survey of nearly 8,000 Air Force recruits with an average age of 19.
"There are major differences between ethnic groups in how early in adolescence they start to smoke," lead study author Dr. Harry A. Lando of the University of Minnesota told Reuters Health.
White recruits, for example, became smokers at an average of 15.5 years of age, Hispanic smokers at 16 years of age and African Americans at an average of nearly 17 years of age. Some whites smoked their first cigarette as early as age 5, Hispanics had their first puff as early as age 6 and the earliest smokers among African Americans tried cigarettes at 7 years of age. The findings are published in the journal Nicotine and Tobacco Research.
"Early age of initiation overall is strongly associated with being more dependent on cigarettes and being less interested in quitting," Lando said.
The earlier an individual started smoking, the more likely they were to be highly dependent on nicotine--at least in whites and Hispanics. There was no link between the two in African-American recruits.
For all three ethnic groups, the earlier recruits started smoking the less likely they were to want to quit.
Those African Americans and Hispanic recruits who started smoking at a very early age were four and five times less likely to intend to quit after basic military training than their peers who began smoking at 18 years and older, note Lando and his colleagues. Whites who began smoking earlier--between 5 and 14 years of age--were two times less likely to intend to quit than those who began smoking at 17 years of age or older.
Early smoking was associated with a number of other unhealthy lifestyle factors, such as less exercise (among whites), and more frequent binge drinking and less seatbelt use among whites and Hispanics, Lando said.
In all three ethnic groups, early smoking was associated with a higher intake of high fat foods, and a greater tendency to agree with the statement that "taking illegal drugs was worth the risks involved," the authors write.
Acknowledging that the "underlying reasons for these differences are not fully clear," the authors called for further research in an older, more representative population.
"From the results of this and other studies, even if smoking cannot be prevented, it appears useful to delay onset as long as possible," Lando added. "The current findings underscore the importance of enforcing age of sale laws and of keeping tobacco products out of the hands of minors."
SOURCE: Nicotine and Tobacco Research 2000;2:337-344.

Child Laborers in India Are More Prone to Illness 
A study from Mumbai, India, shows that working children suffer from an increased incidence of respiratory and gastrointestinal illness.
"There is scant information on child labor from rural areas. The present study was, therefore, conducted to determine the possible socioeconomic factors and common childhood illnesses associated with child labor in rural areas", writes Dr. A. S. Daga in the December issue of Indian Pediatrics.
Dr. Daga, from the Grant Medical College, in Mumbai, and colleagues conducted this study in the Dahanu block of Thane district in Maharashtra in October 1997. Among 1,679 children between the ages of 6-14, 62 (3.8%) were working.
The prevalence of diarrhea, acute respiratory infections, worm infestation and malaria was higher among working children than those not working. The risk of child labor was higher when the parents had less than 5 years of formal education, parents who were unskilled workers, children who had no education and when family income was less than rupees 500 ($11) per month.
Of children receiving no schooling, 96.8% were working, and 92% of children whose fathers were unskilled workers were child laborers, the investigators found. More than 85% of children belonging to families with an income less than 500 rupees a month were working
The incidence of acute respiratory infections among working children was 98.3%, diarrhea was seen in 56.2%, helminthiasis in 53%, and malaria in 34%.
Studies from India and abroad have found high rates of malnutrition and ill-health among working children, as did Dr. Daga and colleagues, who found that 77.4% of boys and 88.5% of girls were malnourished. "Child labor is associated with socioeconomic compulsions. Therefore, it is expected to be associated with other parameters of socioeconomic underdevelopment," he writes.
SOURCE: Indian Pediatr 2000;37:1359-1360.

School-Based Approach to Smoking Prevention Fails
School districts show remarkable similarity in the percentage of students who are smoking after graduation, regardless of their participation in a long-term social-influences smoking cessation program. Dr. Arthur V. Peterson, Jr., of the Fred Hutchinson Cancer Research Center, in Seattle, and associates conclude that the school-based approach is a "major failure" in the long-term deterrence of smoking.
In a 15-year trial, 40 Washington school districts were randomized to the Hutchinson Smoking Prevention Project, which includes 65 classroom lessons, or to no intervention. A total of 8388 students in the third grade were enrolled and followed until 2 years after high school. The intervention met guidelines by the National Cancer Institute-sponsored Expert Advisory Panel and the Centers for Disease and Control and Prevention.
The investigators observed no substantial difference in smoking prevalence among girls or boys in the two groups at grade 12 or 2 years later. Average smoking prevalence at grade 12 was 24.4% among the 20 school districts in the intervention group and 24.7% among the control districts.
As reported in the December 20th issue of the Journal of the National Cancer Institute, a similar lack of impact was observed regarding measures of current smoking, cumulative smoking, and grades at which students first began smoking.
Dr. Peterson's team concludes, "It may be time for an altogether new approach that incorporates different theories, different intervention strategies, different venues, and/or different providers."
In an accompanying editorial, Dr. Richard R. Clayton and associates, from the University of Kentucky, in Lexington, describe this work as being "destined to become the gold standard in prevention science."
Dr. Clayton and his associates suggest "reorienting the prevention field from the main effects question (what works?) to the moderated model question (what works, for whom, under what conditions, how, and why?)."
SOURCE: Journal of the National Cancer Institute 2000;92:1964-1965,1979-1991.

Young Marijuana Smokers at Highest Addiction Risk
People who begin using marijuana early are more likely than others to become dependent, new findings show.
In a study of over 2700 marijuana users in Ontario, Canada, those who started smoking at 17 years or later were twice as likely to eventually quit compared with those who started at 14 years or younger.
"We believe this study has uncovered important information regarding the effects of patterns of marijuana use on the risk of desistance and progression to marijuana-related harm," Dr. David J. DeWit, of the Centre for Addiction and Mental Health, in London, Ontario, and Canadian colleagues say in the November issue of Preventive Medicine.
"We observed a significant ... relationship between frequency of lifetime marijuana use and marijuana desistance," the authors say.
Compared with infrequent use, a lifetime frequency of 100 to 199 uses predicted an almost five-fold higher likelihood of developing marijuana disorders, they report.
"Prevention programs that are effective in delaying initiation of marijuana use until the age of 16 and beyond may greatly diminish the likelihood of prolonged consumption and consequently serve to avert serious problems later in life," DeWit and colleagues conclude.
SOURCE: Preventive Medicine 2000;31:455-464

Children's Anxiety at an All-time High
Looking back on "the good old days" through rose-colored glasses can seem like a grownup's favorite pastime. But recent findings suggest that in some ways, these adults may be onto something.
According to a study published in the December issue of the Journal of Personality and Social Psychology, children and young adults today feel more anxious compared with their counterparts in the 1950s.
In fact, healthy children reported more anxiety during the 1980s than child psychiatric patients reported 30 years earlier.
"Contrary to views that children have nothing to worry about except bullies and Oedipal dynamics, these findings indicate that children's anxiety strongly reflects what is happening in the society at large," concludes study author Dr. Jean M. Twenge, from Case Western Reserve University in Cleveland, Ohio.
For example, crime and fears of AIDS, as well as social isolation caused by high divorce rates, might underlie higher levels of anxiety among today's young people. In an interview with Reuters Health, Twenge added that people increasingly say that they do not trust others.
"We see our world as a more threatening place and we do not feel the same sense of community that we did during the 1950s," she explained.
The findings suggest that personality is not determined by genes alone. The study results also point to an increase in depression and substance abuse, which can be consequences of anxiety, Twenge notes.
She said that limiting children's exposure to violence in the media, helping them to maintain friendships, and talking to them about their worries and fears might lower levels of anxiety among young people.
The analysis is based on two studies that looked at more than 60,000 children and college students over four decades. Both groups experienced increasing levels of anxiety and neuroticism from the 1950s to the 1990s.
The study notes that while crime and fears about nuclear war have declined somewhat, divorce rates remain high and the number of people who live alone remains high.
"Improvements in these statistics, and a general feeling of belongingness and closeness in our communities, would likely decrease feelings of anxiety. Until people feel both safe and connected to others, anxiety is likely to remain high," Twenge concludes.
SOURCE: Journal of Personality and Social Psychology 2000;79:1007-1021.

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