Microsomal triglyceride transfer protein polymorphisms and lipoprotein levels in type 2 diabetes

BACKGROUND

Microsomal triglyceride transfer protein (MTP) regulates the assembly of chylomicrons in the intestine and very-low-density lipoprotein (VLDL) in the liver. Common polymorphisms have been described that do not affect lipoproteins in non-diabetic subjects. Their effect in diabetes has not been described in a Caucasian population.

AIM

To investigate the association of these three common polymorphisms with lipoproteins in type 2 diabetes.

METHODS

Eighty-two patients consumed a high-fat test meal. Chylomicron and VLDL apoB48, apoB100, cholesterol, triglycerides and phospholipids were measured fasting, and at 4 and 6 h postprandially. MTP genotyping was performed by PCR-RFLP.

RESULTS

Thirty-three subjects were heterozygous for the -493 G/T substitution. These patients had significantly lower LDL cholesterol (3.0 +/- 0.2 vs. 3.5 +/- 0.1 mmol/l, p < 0.02). In the postprandial period, they had higher levels of apoB48 in the VLDL fraction (4 h, 7.0 +/- 1.4 vs. 2.9 +/- 0.4 microg/ml plasma, p < 0.002; 6 h, 6.4 +/- 1.0 vs. 3.5 +/- 0.5 microg/ml plasma, p < 0.05). In the VLDL fraction there was significantly less cholesterol at 4 and 6 h (p < 0.05). The -400 A/T substitution gave very similar lipoprotein results, but there was significant linkage dysequilibrium between the two polymorphisms. No association was found between the -164 T/C polymorphism and either plasma lipids or the postprandial lipid profile. ApoE genotype was also examined, but did not influence the above results.

DISCUSSION

The common -493 G/T MTP polymorphism is associated with changes in VLDL and LDL in Type 2 diabetic patients. The importance of the changes in apoB48-containing small particles requires further investigation. The significantly lower LDL cholesterol suggests that this polymorphism may confer protection against atherosclerosis in type 2 diabetes.

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co ordination of services following discharge from hospital thereby bridging the gap between hospital and place of discharge. Sometimes discharge planning is offered as part of an integrated package of care, which may cover both the hospital and community. The focus of this review is discharge planning that occurs while a patient is in hospital; we exclude studies that evaluate discharge planning with follow up care.

OBJECTIVES

To determine the effectiveness of planning the discharge of patients moving from hospital.

SEARCH STRATEGY

Relevant studies were identified using Medline, Embase, SIGLE database for grey literature, Bioethics database, Health Plan, Psych. Lit, Sociofile, CINAHL, Cochrane Library, Econ Lit, Social Science Citation Index, EPOC register. The review was updated using the EPOC trials register in August 2002.

STUDY DESIGN

randomised controlled trials (RCTs) that compare discharge planning (the development of an individualised discharge plan) with routine discharge care.

PARTICIPANTS

all patients in hospital.

INTERVENTION

the development of an individualised discharge plan.

DATA COLLECTION AND ANALYSIS

Data analysis and quality assessment was undertaken independently by two reviewers using a data checklist. Studies are grouped according to patient group (elderly medical patients, surgical patients, and those with a mix of conditions), and by outcome.

MAIN RESULTS

Three new studies were included in this update. In total we included eleven RCTS: 6 trials recruited patients with a medical condition (2,368 patients), and four recruited patients with a mix of medical and surgical conditions (2,983 patients), one of these four recruited medical and surgical patients as separate groups, and the final trial recruited 97 patients in a psychiatric hospital and from a general hospital. We failed to detect a difference between groups in mortality for elderly patients with a medical condition (OR 1.44 95% CI 0.82 to 2.51), hospital length of stay (weighted mean difference -0.86, 95% CI -1.9 to 0.18), readmission rates (OR 0.91 95% CI 0.67 to 1.23) and being discharged from hospital to home (OR 1.15 95% CI 0.72 to 1.82). This was also the case for trials recruiting patients recovering from surgery and those recruiting patients with a mix of medical and surgical conditions. One trial comparing a structured care pathway for patients recovering from a stroke with multidisciplinary care reported a significant rate of improvement in functional ability and quality of life for the control group (median change in Barthel score between 4 to 12 weeks of 2 points for the treatment group, versus 6 for the control group, p<0.01); (Euroqol scores at 6 months 63 for the treatment group, vs. 72 for the control group, p<0.005). Two trials reported that patients with medical conditions allocated to discharge planning reported increased satisfaction compared with those who received routine discharge. No statistically significant differences were reported for overall health care costs.

REVIEWER'S CONCLUSIONS

The impact of discharge planning on readmission rates, hospital length of stay, health outcomes and cost is uncertain. This reflects a lack of power as the degree to which we could pool data was restricted by the different reported measures of outcome. It is possible that even a small reduction in length of stay, or readmission rate, could have an impact on the timeliness of subsequent admissions in a system where there is an shortage of acute hospital beds.

How much of a priority is treating erectile dysfunction? A study of patients' perceptions

BACKGROUND

Erectile dysfunction (ED) is one complication of diabetes for which the treatment is rationed. Despite considerable public debate there has been no formal assessment of the views of patients and sufferers of the priority of treating ED.

AIMS

To determine the perceptions of diabetic patients of the relative priority of treating ED in comparison with treatments for other diabetic complications and common medical conditions.

METHODS

Psychological measures were used to assess subjects' perceptions of the relative importance of ED in comparison with eight other common problems (blindness, foot ulcers, high blood pressure, impotence, kidney disease, high cholesterol, migraine, mild indigestion and sleeping difficulties). The concept of willingness to pay was used to assess the amount per month participants would be prepared to pay for treatment for ED and other conditions. Four groups (controls, healthy diabetic men, impotent diabetic men and impotent diabetic men not in a sexual relationship) were studied.

RESULTS

Significant differences were found between the four groups with regard to the ranking of the importance of ED compared with other health problems. Impotent diabetic male patients were prepared to pay more for treatment for their condition than all other conditions except blindness and renal failure.

CONCLUSIONS

Men with diabetes, in particular ED sufferers, believe ED has a major impact on quality of life and is as important to treat as many other conditions associated with diabetes.

Provision of chlamydia testing in a nationwide service offering termination of pregnancy: with data capture to monitor prevalence of infection

OBJECTIVES

To establish a methodology by which all women attending for termination of pregnancy (TOP) at British Pregnancy Advisory Service (BPAS) branches may be approached to participate in Chlamydia trachomatis screening. To examine the feasibility of monitoring C trachomatis prevalence and the impact of charging for screening on the uptake rate in this population.

METHODS

Patients attending for TOP at participating BPAS branches were offered a test for chlamydia infection and asked to complete a questionnaire. Urine samples from participants were tested using a nucleic acid amplification test (NAAT).

RESULTS

1001 women provided a urine sample, a 77% response rate among those participating in the study. Factors significantly associated with taking up chlamydia screening included symptoms, previous TOP, parity, and no previous chlamydial test. Overall prevalence of genital chlamydial infection was 7.5%, with highest age specific prevalences occurring among attendees aged 20-24 years (11.5%) and under 20 years (10.8%). In univariate analysis, chlamydia positivity was significantly associated with respondent age and previous diagnosis with chlamydia. Only 35% of women who had the screening test would have done so had they been asked to pay the pound 20 clinical, administrative, and laboratory costs of the examination.

CONCLUSIONS

We have demonstrated the feasibility of routine chlamydia screening and the potential for prospective prevalence monitoring across the nationwide BPAS service. In most cases the chlamydia result was available within the clinical contact period for the TOP. Charging patients directly for the test could reduce uptake of chlamydia screening to levels unsatisfactory for both the public health and prevalence monitoring purposes.

Classical and Bayesian inference in neuroimaging: applications

In Friston et al. ((2002) Neuroimage 16: 465-483) we introduced empirical Bayes as a potentially useful way to estimate and make inferences about effects in hierarchical models. In this paper we present a series of models that exemplify the diversity of problems that can be addressed within this framework. In hierarchical linear observation models, both classical and empirical Bayesian approaches can be framed in terms of covariance component estimation (e.g., variance partitioning). To illustrate the use of the expectation-maximization (EM) algorithm in covariance component estimation we focus first on two important problems in fMRI: nonsphericity induced by (i) serial or temporal correlations among errors and (ii) variance components caused by the hierarchical nature of multisubject studies. In hierarchical observation models, variance components at higher levels can be used as constraints on the parameter estimates of lower levels. This enables the use of parametric empirical Bayesian (PEB) estimators, as distinct from classical maximum likelihood (ML) estimates. We develop this distinction to address: (i) The difference between response estimates based on ML and the conditional means from a Bayesian approach and the implications for estimates of intersubject variability. (ii) The relationship between fixed- and random-effect analyses. (iii) The specificity and sensitivity of Bayesian inference and, finally, (iv) the relative importance of the number of scans and subjects. The forgoing is concerned with within- and between-subject variability in multisubject hierarchical fMRI studies. In the second half of this paper we turn to Bayesian inference at the first (within-voxel) level, using PET data to show how priors can be derived from the (between-voxel) distribution of activations over the brain. This application uses exactly the same ideas and formalism but, in this instance, the second level is provided by observations over voxels as opposed to subjects. The ensuing posterior probability maps (PPMs) have enhanced anatomical precision and greater face validity, in relation to underlying anatomy. Furthermore, in comparison to conventional SPMs they are not confounded by the multiple comparison problem that, in a classical context, dictates high thresholds and low sensitivity. We conclude with some general comments on Bayesian approaches to image analysis and on some unresolved issues.

Classical and Bayesian inference in neuroimaging: theory

This paper reviews hierarchical observation models, used in functional neuroimaging, in a Bayesian light. It emphasizes the common ground shared by classical and Bayesian methods to show that conventional analyses of neuroimaging data can be usefully extended within an empirical Bayesian framework. In particular we formulate the procedures used in conventional data analysis in terms of hierarchical linear models and establish a connection between classical inference and parametric empirical Bayes (PEB) through covariance component estimation. This estimation is based on an expectation maximization or EM algorithm. The key point is that hierarchical models not only provide for appropriate inference at the highest level but that one can revisit lower levels suitably equipped to make Bayesian inferences. Bayesian inferences eschew many of the difficulties encountered with classical inference and characterize brain responses in a way that is more directly predicated on what one is interested in. The motivation for Bayesian approaches is reviewed and the theoretical background is presented in a way that relates to conventional methods, in particular restricted maximum likelihood (ReML). This paper is a technical and theoretical prelude to subsequent papers that deal with applications of the theory to a range of important issues in neuroimaging. These issues include; (i) Estimating nonsphericity or variance components in fMRI time-series that can arise from serial correlations within subject, or are induced by multisubject (i.e., hierarchical) studies. (ii) Spatiotemporal Bayesian models for imaging data, in which voxels-specific effects are constrained by responses in other voxels. (iii) Bayesian estimation of nonlinear models of hemodynamic responses and (iv) principled ways of mixing structural and functional priors in EEG source reconstruction. Although diverse, all these estimation problems are accommodated by the PEB framework described in this paper.

Nightguard vital bleaching: a long-term study on efficacy, shade retention. side effects, and patients' perceptions

BACKGROUND

The scientific literature is lacking in long-term clinical data on the duration of efficacy and post-treatment side effects of nightguard vital bleaching.

PURPOSE

This longitudinal clinical study was undertaken (1) to determine the clinical efficacy and duration of efficacy at 3, 6, and 47 months post treatment of a peroxide-containing whitening solution; (2) to evaluate safety issues with respect to using a peroxide whitening solution; and (3) to determine patients' perceptions of the whitening technique.

MATERIALS AND METHODS

This project was part of a nightguard vital bleaching study involving human participants. The study teeth for efficacy and duration of efficacy when using a 10% carbamide peroxide solution were the four maxillary central and lateral incisors, with the tooth shade being taken from the middle third of the tooth. Safety issues evaluated were the changes in gingival index (GI), plaque index (PI), nonmarginal gingival index (NMGI), nongingival oral mucosal index (NGOMI), and tooth vitality (TV). Radiographic changes of the study teeth and the patients' perceptions of tooth sensitivity (TS) or gingival irritation (Girr) during treatment and post treatment were also evaluated.

RESULTS

The active 10% carbamide peroxide whitening solution used in this study was effective in lightening teeth (98%), and this effect was sustained at a mean of 47 months post treatment in 82% of the participants. When evaluating safety issues, 66% of the participants using the active solution reported TS or Girr. No one reported TS or Girr or any other adverse effects at the end of the study.

CONCLUSIONS

The results of this study concur with those of previously reported studies that nightguard vital bleaching using a 10% carbamide peroxide whitening solution according to the manufacturer's instructions is efficacious and safe, with minimal side effects. In addition, long-term shade retention was reported by 82% of the participants at the end of the study, with no adverse side effects.

CLINICAL SIGNIFICANCE

Results of this study should reassure dentists that nightguard vital bleaching is a safe, effective, and predictable method to lighten teeth. The whitening effect lasted up to 47 months in 82% of the patients, with no adverse side effects reported at the end of the study.

Microsomal triglyceride transfer protein: does insulin resistance play a role in the regulation of chylomicron assembly?

We have previously demonstrated that diabetes is associated with an increase in intestinal microsomal triglyceride transfer protein (MTP) mRNA in both the rat and rabbit models. The present study was designed to investigate the relationship between MTP expression and chylomicron assembly in an insulin resistant non-diabetic animal model. Ten insulin resistant Zucker obese fa/fa rats and ten lean fa/minus sign rats were examined at 8-10 weeks of age. The lymph duct was cannulated and lymph collected for 4 h. Lymph chylomicrons were isolated by ultracentrifugation and their composition determined. RNA was extracted from intestinal mucosa and from the liver. MTP mRNA was measured using the RNase protection assay. Blood sugar in the fatty rats was significantly higher (6.3 +/-1.2 vs. 5.4 +/-0.4 P<0.05) and plasma insulin was almost six times that of the lean rats (P<0.001). Plasma cholesterol and phospholipid but not triglyceride were significantly increased in the obese animals (P<0.01). Obese animals secreted significantly more lymph chylomicron apo B48 (0.05 +/-0.02 vs. 0.02 +/-0.01 mg/h P<0.005), triglyceride (9.7 +/-5.3 vs. 3.8+/-1.9 mg/h P<0.005) and phospholipid (1.5 +/-0.7 vs. 0.4 +/-0.3 mg/h P<0.001). The only difference in the chylomicron particle composition between the two groups was a significant increase in phospholipid (P<0.01). Intestinal MTP mRNA expression was significantly higher in the fatty compared to the lean rats (22.1 +/-9.5 vs. 7.8+/-5.6 amol MTP mRNA/microg total RNA P<0.001) as was hepatic MTP mRNA expression (6.9 +/-3.5 vs. 3.4 +/-1.5 amol MTP mRNA/microg total RNA, P<0.01). Thus in this animal model of insulin resistance, increased MTP, which was associated with increased chylomicron particle number, may play a crucial role in the development of atherosclerosis.

Regulation of nuclear poly(A) addition controls the expression of immunoglobulin M secretory mRNA

B-cell differentiation is accompanied by a dramatic increase in cytoplasmic accumulation and stability of the IgM heavy chain (mu) secretory mRNA. Despite considerable effort, the mechanism is unknown. We have identified three short motifs upstream of the secretory poly(A) site, which, when mutated in the mu heavy chain gene, significantly increase the accumulation of the secretory form of poly(A)(+) mRNA relative to the membrane form and regulate the expression of the secretory poly(A) site in a developmental manner. We show that these motifs bind U1A and inhibit polyadenylation in vitro and in vivo. Overexpression of U1A in vivo results in the selective inhibition of the secretory form. Thus, this novel mechanism selectively controls post-cleavage expression of the mu secretory mRNA. We present evidence that this mechanism is used to regulate alternative expression of other genes.

Experience-dependent changes in cerebral functional connectivity during human rapid eye movement sleep

One function of sleep is hypothesized to be the reprocessing and consolidation of memory traces (Smith, 1995; Gais et al., 2000; McGaugh, 2000; Stickgold et al., 2000). At the cellular level, neuronal reactivations during post-training sleep in animals have been observed in hippocampal (Wilson and McNaughton, 1994) and cortical (Amzica et al., 1997) neuronal populations. At the systems level, using positron emission tomography, we have recently shown that some brain areas reactivated during rapid-eye-movement sleep in human subjects previously trained on an implicit learning task (a serial reaction time task) (Maquet et al., 2000). These cortical reactivations, located in the left premotor area and bilateral cuneus, were thought to reflect the reprocessing--possibly the consolidation--of memory traces during post-training rapid-eye-movement sleep. Here, the experience-dependent functional connectivity of these brain regions is examined. It is shown that the left premotor cortex is functionally more correlated with the left posterior parietal cortex and bilateral pre-supplementary motor area during rapid-eye-movement sleep of subjects previously trained to the reaction time task compared to rapid-eye-movement sleep of untrained subjects. The increase in functional connectivity during post-training rapid-eye-movement sleep suggests that the brain areas reactivated during post-training rapid-eye-movement sleep participate in the optimization of the network that subtends subject's visuo-motor response. The optimization of this visuo-motor network during sleep could explain the gain in performance observed during the following day.

Nightguard vital bleaching and its effect on enamel surface morphology

BACKGROUND

The effect that nightguard vital bleaching (NGVB) has on enamel surface morphology is a subject of debate. Previous studies that have evaluated the effect of NGVB on the enamel surface report minimal changes to changes that appear to worsen post-treatment. The purpose of this in vivo NGVB study was to evaluate by scanning electron microscopy (SEM) the effects that 10% carbamide peroxide has on enamel morphology after 2 weeks of treatment and at 6 months post-treatment.

MATERIALS AND METHODS

Ten patients participated in the study. Each participant wore a guard filled with an active whitening solution for 8 to 10 hours per day for 14 treatment days. An impression of the study teeth (maxillary incisors) was taken at baseline, after 14 days of treatment, and at 6 months post-treatment, and an epoxy cast made. The epoxy casts were prepared for viewing under the SEM and photographs were taken at 200 times and 2,000 times magnification. Six examiners evaluated changes in enamel surface morphology by comparing the SEM photographs taken at baseline, on treatment day 14, and at 6 months post-treatment. Still masked, the examiners also compared each patient's baseline:treatment day 14 and baseline:6 months post-treatment photographs with photographs of a known standard.

RESULTS

This in vivo study demonstrated that a 14-day regimen of NGVB using a 10% carbamide peroxide solution had minimal effect on the surface morphology of enamel and that the effects did not worsen over time.

Results of a collaborative study of the EDNAP group regarding the reproducibility and robustness of the Y-chromosome STRs DYS19, DYS389 I and II, DYS390 and DYS393 in a PCR pentaplex format

A collaborative exercise was carried out by the European DNA Profiling Group (EDNAP) in the frame work of the STADNAP program, i.e. standardization of DNA profiling in Europe, in order to evaluate the performance of a Y-chromosome STR pentaplex, which includes the loci DYS19, DYS389 I and II, DYS390 and DYS393 and to determine whether uniformity of results could be achieved among different European laboratories. Laboratories were asked to analyze the five Y-STRs using singleplex and multiplex conditions in three bloodstains and one mixed stain (95% female and 5% male). All the laboratories reported the same results even for the mixed stain included in the exercise. This demonstrates the reproducibility and robustness of Y-chromosome STR typing even with multiplex formats and proves the usefulness of Y-STR systems for analyzing mixed stains with a male component.A total of 930 male samples from 10 different populations from Europe were also analysed for all the loci included in the pentaplex. Eight of these ten populations also included haplotype data. As for single gene analysis, haplotype diversity was higher in Germany and Italy and lower in Western European countries and Finland. Pairwise haplotype analysis shows the Finnish departure from the rest of the populations and a relatively homogeneity in the other European populations with F(ST) estimates lower than 0.05.UPGMA analysis shows an association of Western European population (Ireland, UK, Portugal and Galicia) on the one hand and central European populations on the other.

Meta-analysis of dietary restriction during fecal occult blood testing

CONTEXT

Dietary restriction is often recommended during fecal occult blood testing (FOBT) as a means of increasing test accuracy, but concern surrounds whether such restriction also reduces the chance that patients will complete the test.

PURPOSE

We conducted a systematic review and meta-analysis to determine if advice about dietary restrictions affects the rate of completion of FOBT and the rate of positive results.

METHODS

We searched the MEDLINE database and hand-searched the bibliographies of other systematic reviews and clinical practice guidelines to identify randomized trials of advice to perform dietary restriction during FOBT. We included only trials that reported the proportion of patients who completed the occult blood tests (completion rate). When such information was available, we also recorded the proportion of patients who had positive test results (positivity rate).

RESULTS

Five randomized trials met our inclusion criteria. All used guaiac-based Hemoccult tests; none reported results from rehydrated test slides. In four trials, there was little or no difference in test completion between patients assigned to dietary restriction and those with no restriction. In one small trial that used an especially restrictive diet, completion was 21 percentage points lower in the restricted group. Positivity rates were reported in four trials, none of which found a statistically significant difference between groups. Meta-analysis showed no difference in the summary positivity rate between those assigned to dietary restriction versus those not restricted (difference in positivity rate, 0%; 95% CI, -1% to 1%).

CONCLUSIONS

Available data suggest that advice to perform modest dietary restriction during unrehydrated FOBT does not affect the completion rate, but more severe restrictions may. Dietary restriction also does not appear to affect positivity rates. On the basis of these data, physicians do not need to advise patients to restrict their diet for nonrehydrated FOBTs.

Assessment of constipation management in long-term care patients

OBJECTIVES

To determine the prevalence of diagnosed constipation among nursing home patients; to assess the prevalence of routine (at least one time per week for 4 consecutive weeks) laxative use; and to investigate prescribing practices.

DESIGN

A retrospective multi-center medical record evaluation.

SETTING

Any one of 25 nursing facilities representative of a long-term care pharmaceutical provider's geographical coverage.

PARTICIPANTS

All patients under the age of 65, and/or who had resided in the facility for less than 4 weeks, and/or who were placed in a specialty care bed (eg, Alzheimer's disease, hospice, HIV/AIDS) were excluded.

RESULTS

A total of 712 resident charts meeting initial inclusion criteria were screened, 392 (55%) of which had a documented diagnosis of constipation and/or routine laxative use. Approximately 28% (CI +/- 3.3) of residents had a documented diagnosis of constipation. The rate of laxative use within the same sample population of 712 patients was 53.8% (CI +/- 3.7). Of the 392 patients with a diagnosis of constipation and/or routine laxative use, over 72% had at least one diagnosis or medication known to precipitate constipation. The most commonly prescribed laxatives were stool softeners (26.2%), saline laxatives (18.4%) and stimulant/irritant laxatives (15.6%). Almost half of the laxative users were prescribed more than one agent.

CONCLUSION

This study supports the concern that there is often a gap between documentation of symptoms and constipation treatment decisions. No correlation was found between the specific laxative prescribed and the presence or absence of a documented diagnosis of constipation. Treatment decisions should be based on thorough examination and individualized patient needs. Furthermore, there is a need to increase monitoring for drug effectiveness.

Exploring women's beliefs regarding urinary incontinence

The purpose of this study was to explore and describe women's beliefs, knowledge, and need for education regarding female urinary incontinence (UI). Findings suggest that almost half of the women surveyed believed UI was normal. A majority believed it is a problem for women, but felt they could not talk about it freely. Most knew professional help was available and indicated they would seek help if incontinent, but expressed a need for more information. They varied in their beliefs regarding the efficacy of various treatment modalities. Implications for nursing practice are discussed.

Does the mode of inhalation affect the bronchodilator response in patients with severe COPD?

Spacing devices improve lung deposition of aerosols from metered dose inhalers (MDI) but it is sometimes difficult for dyspnoeic patients to perform maximal breaths with breath-holds needed to inhale the aerosols from them. Our aim was to determine whether the response to bronchodilators (BD) depended on the method of inhalation. We studied 20 patients with moderately severe chronic obstructive pulmonary disease (COPD) with a mean age of 68 years and a mean of forced expiratory volume in 1 sec (FEV1) of 41% predicted. In a randomized, cross-over fashion they inhaled terbutaline 1.5 mg (six puffs) followed by ipratropium 120 microg (six puffs) via MDI and nebuhaler with either two inspirations to total lung capacity and a 10-sec breath-hold per puff or with six tidal breaths per puff. Before and after BDs we measured FEV1, forced vital capacity (FVC), airways resistance using interrupter method (Rint) and 6-min walking distance (6MWD). Subsequently, we re-tested nine of these patients with the two methods of inhalation, before and after conventional doses (terbutaline 500 microg+ipratropium 40 microg), then after terbutaline 1 mg and ipratropium 80 microg and finally after nebulized terbutaline 5 mg and ipratropium 500 microg to sec whether there was a dose-dependent difference in effect between the two methods. Spirometry, slow vital capacity (SVC). inspiratory capacity and shuttle walking tests were monitored. In the original 20 patients there were highly significant improvements in all parameters after inhalers, with no significant difference between methods of inhalation. Median improvements after BDs were: FEV1 0.221 and 0.191, FVC 0.501 and 0.381 and 6MWD 40 m and 44 m, for maximal breaths and tidal breathing, respectively. For nine patients, tidal and maximal breaths produced similar effects on lung function and exercise tolerance at both doses of BDs. Nebulized BDs only improved shuttle distances slightly when compared with either method of inhalation from MDI and spacer but had no additional effect on lung function. In conclusion, in patients with moderately severe COPD, BDs given by metered dose inhaler via nebuhaler have similar effects whether given by six easy tidal breaths or the more difficult two maximal breaths with breath-hold. This holds true at small or larger doses of BD. Either method of inhaling six puffs of the BDs can be used as an effective alternative to nebulized aerosol.

A longitudinal assessment of diverging verbal and non-verbal abilities in the Williams syndrome phenotype

Jarrold et al. (1998) presented evidence to suggest that verbal and non-verbal abilities develop at different rates in individuals with the Williams syndrome phenotype. However, this evidence was derived from cross-sectional rather than longitudinal data. The current report presents data from a series of follow up assessments which examine the development of vocabulary and pattern construction abilities in 15 of the original sample of 16 individuals, over a 40 month period. The results confirm the original predictions, as mental age equivalent scores for vocabulary increase more rapidly than scores for the pattern construction test; a finding, which appears unlikely to be due to practice effects.

Health department clinics as pediatric immunization providers: a national survey

OBJECTIVE

To describe a national sample of health department immunization clinics in terms of populations served, patient volume trends, services offered, and immunization practices.

METHODS

Telephone survey conducted with health departments sampled from a national database, using probability proportional to population size.

RESULTS

All (100%) 166 sampled and eligible clinics completed the survey. The majority of pediatric patients were uninsured (42%) or enrolled in Medicaid (34%). Most children (69%) and adolescents (70%) were referred to the health department, with only 12% using these clinics as a medical home. A number of clinics (72%) reported recent increases in adolescents served. Less than 25% of clinics offered comprehensive care, 47% conducted semiannual coverage assessments, and 76% and 38% operated recall systems for children and adolescents. Storage of records in an electronic database was common (83%).

CONCLUSIONS

Although the majority of these clinics do not provide comprehensive care, they continue to serve vulnerable children, including adolescents, Medicaid enrollees, and the uninsured, and may represent the main contact with the healthcare system for such patients. Because assuring the immunization of these children is essential to their health and the health of our nation as a whole, this immunization safety net must be preserved. Experience implementing key recommendations such as coverage assessment and feedback as well as reminder or recall may enable health department staff to assist private provider colleagues. Further research is needed to investigate how patient populations, services offered, and immunization practices vary by different clinic characteristics.