The role of insulin-like-growth factor binding protein 2 (IGFBP2) and phosphatase and tensin homologue (PTEN) in the regulation of myoblast differentiation and hypertrophy

The complex actions of the insulin-like-growth factor binding proteins (IGFBPs) in skeletal muscle are becoming apparent, with IGFBP2 being implicated in skeletal muscle cell proliferation and differentiation (Ernst et al., 1992; Sharples et al., 2010). Furthermore, PTEN signalling has been linked to IGFBP2 action in other cell types by co-ordinating downstream Akt signalling, a known modulator of myoblast differentiation. The present study therefore aimed to determine the interaction between IGFBP2 and PTEN on myoblast differentiation. It has previously been established that C2C12 cells have high IGFBP2 gene expression upon transfer to low serum media, and that expression reduces rapidly as cells differentiate over 72 h [1]. Wishing to establish a potential role for IGFBP2 in this model, a neutralising IGFBP2 antibody was administered to C2C12 myoblasts upon initiation of differentiation. Myoblasts subsequently displayed reduced morphological differentiation (myotube number), biochemical differentiation (creatine kinase) and myotube hypertrophy (myotube area) with an early reduction in Akt phosphorylation. Knock-down of phosphatase and tensin homologue (PTEN) using siRNA in the absence of the neutralising antibody did not improve differentiation or hypertrophy vs. control conditions, however, in the presence of the neutralising IGFBP2 antibody, differentiation was restored and importantly hypertrophy exceeded that of control levels. Overall, these data suggest that; 1) reduced early availability of IGFBP2 can inhibit myoblast differentiation at later time points, 2) knock-down of PTEN levels can restore myoblast differentiation in the presence of neutralising IGFBP2 antibody, and 3) PTEN inhibition acts as a potent inducer of myotube hypertrophy when the availability of IGFBP2 is reduced in C2C12 myoblasts.

Identification of novel breast cancer-associated transcripts by UniGene database mining and gene expression analysis in normal and malignant cells

Breast cancer is a heterogeneous and complex disease. Although the use of tumor biomarkers has improved individualized breast cancer care, i.e., assessment of risk, diagnosis, prognosis, and prediction of treatment outcome, new markers are required to further improve patient clinical management. In the present study, a search for novel breast cancer-associated genes was performed by mining the UniGene database for expressed sequence tags (ESTs) originating from human normal breast, breast cancer tissue, or breast cancer cell lines. Two hundred and twenty-eight distinct breast-associated UniGene Clusters (BUC1-228) matched the search criteria. Four BUC ESTs (BUC6, BUC9, BUC10, and BUC11) were subsequently selected for extensive in silico database searches, and in vitro analyses through sequencing and RT-PCR based assays on well-characterized cell lines and tissues of normal and cancerous origin. BUC6, BUC9, BUC10, and BUC11 are clustered on 10p11.21-12.1 and showed no homology to any known RNAs. Overall, expression of the four BUC transcripts was high in normal breast and testis tissue, and in some breast cancers; in contrast, BUC was low in other normal tissues, peripheral blood mononuclear cells (PBMCs), and other cancer cell lines. Results to-date suggest that BUC11 and BUC9 translate to protein and BUC11 cytoplasmic and nuclear protein expression was detected in a large cohort of breast cancer samples using immunohistochemistry. This study demonstrates the discovery and expression analysis of a tissue-restricted novel transcript set which is strongly expressed in breast tissue and their application as clinical cancer biomarkers clearly warrants further investigation.

The influence of fault on health in the immediate post-crash period following road traffic crashes

OBJECTIVE

To compare the early health status of people who sustained injuries during road traffic crashes (RTC) in which they were at fault (AF), with people who sustained injuries in RTC in which they were not at fault (NAF).

DESIGN

Prospective cohort study.

SUBJECTS

People presenting to the emergency department with mild to moderate musculoskeletal injuries following RTC.

MAIN OUTCOME MEASURES

Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI) recorded immediately post-crash.

RESULTS

193 people participated in the study and were enrolled a mean of 9.3 days following the crash. The mean age was 37 years and 60% were female. 71% were NAF. There was a significantly higher number of females in the NAF group (65% compared with 35% males; p<0.001). Neck and back injuries were reported by 90.4% of the NAF group compared to 69.1% of the AF group (p<0.001). There were no significant differences in PCS, FRI or pain intensity between the two groups at a mean of 9.3 days after the crash. The mean MCS for the NAF group was significantly worse than for the AF group (31.4 compared to 37.3; p = 0.005). The SF-36 domain revealed a significantly worse adjusted mean role emotional score for the NAF group (23.4 compared to 32.5, p = 0.002). Females had significantly worse MCS score than males (30.6 and 38.1 respectively; p<0.001) and worse adjusted mean anxiety and depression scores (10 compared to 7.8; p = 0.002 and 7.6 compared to 5.5; p = 0.002 respectively).

CONCLUSIONS

Despite there being no difference in physical health status, the NAF group demonstrated more emotional and mental disturbance than the AF group; and this was significantly worse for females. Treatment strategies should focus on addressing early pain and disability as well as providing appropriate psychological interventions, particularly for people not at fault following RTC.

The association of compensation on longer term health status for people with musculoskeletal injuries following road traffic crashes: emergency department inception cohort study

OBJECTIVE

To compare the health status of people claiming compensation for injuries sustained in road traffic crashes (RTC), with people who do not claim compensation.

DESIGN

Prospective cohort study.

SETTING

Australian Capital Territory, Australia and a fault based common law compensation scheme.

SUBJECTS

People presenting to the emergency department with mild to moderate musculoskeletal injury following RTC.

MAIN OUTCOME MEASURES

Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure, Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI). These measures are recorded immediately post crash, at 6 and 12 months post crash.

RESULTS

95 people participated in the study and were enrolled a mean of 8.6 (median 8) days following the crash. 86% were followed up to 12 months after injury. Mean age was 37 years, 61% were female and 91% were employed at the time of their injury.33%ultimately claimed compensation, and 25% engaged a lawyer. There were no major differences in baseline personal characteristics or injury related factors between the groups. As expected, involvement as a passenger and in multiple vehicle crashes, were more frequent in the group claiming compensation. Over the duration of the study claiming compensation was associated with lower SF-36 PCS (5.5 (95%CI 8.6 to 2.4), p = 0.001), greater HADS-Anxiety (1.7 (95%CI 0.2–3.3), p = 0.048), and worse FRI (11.2 (95%CI 3.9–18.5), p = 0.003). There was a highly significant improvement in health status between baseline and 6 months after injury, but no further significant change between 6 and 12 months after injury. There was no difference in rate of improvement between the groups. Claiming compensation and psychological factors were independent predictors of worse health status at 12 months.

CONCLUSION

In this study the group claiming compensation had overall worse health status following mild to moderate musculoskeletal injuries over the course of the study. There was no difference in rate of improvement between the groups. However, it is not possible to determine whether this negative effect was due to claiming compensation itself or the presence of other unmeasured factors.

Genetics of muscle strength and power: polygenic profile similarity limits skeletal muscle performance

Environmental and genetic factors influence muscle function, resulting in large variations in phenotype between individuals. Multiple genetic variants (polygenic in nature) are thought to influence exercise-related phenotypes, yet how the relevant polymorphisms combine to influence muscular strength in individuals and populations is unclear. In this analysis, 22 genetic polymorphisms were identified in the literature that have been associated with muscular strength and power phenotypes. Using typical genotype frequencies, the probability of any given individual possessing an "optimal" polygenic profile was calculated as 0.0003% for the world population. Future identification of additional polymorphisms associated with muscular strength phenotypes would most likely reduce that probability even further. To examine the genetic potential for muscular strength within a human population, a "total genotype score" was generated for each individual within a hypothetical population of one million. The population expressed high similarity in polygenic profile with no individual differing by more than seven genotypes from a typical profile. Therefore, skeletal muscle strength potential within humans appears to be limited by polygenic profile similarity. Future research should aim to replicate more genotype-phenotype associations for muscular strength, because only five common genetic polymorphisms identified to date have positive replicated findings.

Role of imaging in the diagnosis of acute bacterial meningitis and its complications

Acute bacterial meningitis is a common neurological emergency and a leading cause of death and neurological disability worldwide. Diagnosis is based on clinical and microbiological findings with neuroimaging in the form of CT reserved for those with specific adverse clinical features or when an underlying cause such as mastoiditis is suspected. MRI is extremely useful for detecting and monitoring the complications of meningitis. These can be remembered by the mnemonic HACTIVE (hydrocephalus, abscess, cerebritis/cranial nerve lesion, thrombosis, infarct, ventriculitis/vasculopathy and extra-axial collection). Diffusion weighted imaging (DWI) and magnetic resonance spectroscopy (MRS) are useful to distinguish abscess from other ring enhancing lesions.

Dimensions and ossification of the normal anterior cranial fossa in children

BACKGROUND AND PURPOSE

Interpretation of CT of the anterior skull base in children depends on knowledge of the pattern and chronology of ossification. The purpose of this study was to ascertain the age at which the anterior cranial fossa is fully ossified as assessed on CT examinations.

MATERIALS AND METHODS

This was a retrospective review of 127 CT examinations of children ranging from 1 day to 16 years 7 months of age without known or suspected anterior cranial fossa abnormality. Measurements of the length and width of the anterior skull base and the presence and size of the most anterior unossified portion were determined by 2 investigators.

RESULTS

At birth, the anterior skull base consists mainly of cartilage. There is a wide variation in ossification rates between individuals, but the anterior skull base was fully ossified at 3 years 10 months in all of our cases.

CONCLUSIONS

In healthy individuals, the anterior skull base is fully ossified by 4 years of age.

ZP genes in avian species illustrate the dynamic evolution of the vertebrate egg envelope

The vertebrate egg envelope is composed of a set of related proteins, encoded by the ZP genes. The apparent simplicity of the egg envelope is in contrast to the number of ZP genes identified by conventional cloning and data mining of genome sequences from a number of vertebrates. The vertebrate ZP genes fall into five classes, ZP1, ZP2, ZP3, ZPD and ZPAX. Analysis of chicken genome and EST sequence data has revealed the presence of seven distinct ZP genes, falling into these classes that are expressed in the female reproductive system. Comparison with the repertoire of ZP genes in other vertebrates suggests a major source of diversity in the composition of the egg envelope is a continual process of amplification, diversification and attrition of ZP gene sequences.

When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome

Upper limb stresses are well recognised in tennis, and the normal physiological responses of the humerus to externally applied forces are well defined. Changes to both the microscopic and macroscopic bony architecture are often not apparent on plain radiographs in the early stages of a stress reaction. Bone scintigraphy is more sensitive, but not very specific to subtle changes, as is computer aided tomography. Magnetic resonance imaging (MRI) scans are now used to assess many musculoskeletal injuries, and may allow earlier recognition of changes. This study reports on eight high level tennis players (seven professionals, one highly ranked amateur), who all presented during the course of the 2002 Australian Open and its lead up events. All had an upper limb pain syndrome centred around the elbow. Each underwent an MRI scan. A group of asymptomatic players also had scans of the same area to serve as controls. All symptomatic patients had various levels of bone marrow oedema in their distal humerus, some with periosteal reactions, although most without. No scans revealed a cortical breach. The management of these reactions is problematic in players on an international circuit, as review is sporadic and not always coordinated. The timetabling of international tournaments means it is difficult for top players to obtain adequate rest to avoid injury. Awareness of this early overuse reaction needs to be raised to allow preventive and therapeutic options to be considered to reduce the incidence of this humeral stress response producing an upper limb pain syndrome.

Isolation and mapping the chicken zona pellucida genes: an insight into the evolution of orthologous genes in different species

The avian oocyte is surrounded by a specialized extracellular glycoproteinaceous matrix, the perivitelline membrane, which is equivalent to the zona pellucida (ZP) in mammals and the chorion in teleosts. A number of related ZP genes encode the proteins that make up this matrix. These proteins play an important role in the sperm/egg interaction and may be involved in speciation. The human genome is known to contain ZP1, ZP2, ZP3, and ZPB genes, while a ZPAX gene has also been identified in Xenopus. The rapid evolution of these genes has confused the nomenclature and thus orthologous relationships across species. In order to clarify these homologies, we have identified ZP1, ZP2, ZPC, ZPB, and ZPAX genes in the chicken and mapped them to chromosomes 5, 14, 10, 6, and 3, respectively, establishing conserved synteny with human and mouse. The amino acid sequences of these genes were compared to the orthologous genes in human, mouse, and Xenopus, and have given us an insight into the evolution of these genes in a variety of different species. The presence of the ZPAX gene in the chicken has highlighted a pattern of probable gene loss by deletion in mouse and gene inactivation by deletion, and base substitution in human.

Cracking the egg: increased complexity in the zona pellucida

A functional zona pellucida is critical for both fertilization and the early stages of embryo development. Recent data from genomic and proteomic studies have questioned our simplistic view of the zona as being composed of three proteins whose functions are clearly defined. In the human, for example, the zona pellucida is composed of four proteins, not three. The increased complexity of the zona pellucida in humans and other species across the evolutionary tree now demands that we reconsider our reliance on the mouse model for understanding early fertilization events. Additionally, we are now well placed to examine, for the first time, potential defects in zona genes and their proteins associated with defined pathology.

Four zona pellucida glycoproteins are expressed in the human

BACKGROUND

The zona pellucida (ZP) is an extracellular glycoprotein matrix which surrounds all mammalian oocytes. Recent data have shown the presence of four human zona genes (ZP1, ZP2, ZP3 and ZPB). The aim of the study was to determine if all four ZP proteins are expressed and present in the human.

METHODS

cDNA derived from human oocytes were used to amplify by PCR the four ZP genes. In addition, isolated native human ZP were heat-solubilized, trypsin-digested and subjected to tandem mass spectrometry (MS/MS).

RESULTS

All four genes were expressed and the respective proteins present in the human ZP. Moreover, a bioinformatics approach showed that the mouse ZPB gene, although present, is likely to encode a non-functional protein.

CONCLUSIONS

Four ZP genes are expressed in human oocytes (ZP1, ZP2, ZP3 and ZPB) and preliminary data show that the four corresponding ZP proteins are present in the human ZP. Therefore, this is a fundamental difference with the mouse model

Svp1p defines a family of phosphatidylinositol 3,5-bisphosphate effectors

Phosphatidylinositol 3,5-bisphosphate (PtdIns(3,5)P2), made by Fab1p, is essential for vesicle recycling from vacuole/lysosomal compartments and for protein sorting into multivesicular bodies. To isolate PtdIns(3,5)P2 effectors, we identified Saccharomyces cerevisiae mutants that display fab1delta-like vacuole enlargement, one of which lacked the SVP1/YFR021w/ATG18 gene. Expressed Svp1p displays PtdIns(3,5)P2 binding of exquisite specificity, GFP-Svp1p localises to the vacuole membrane in a Fab1p-dependent manner, and svp1delta cells fail to recycle a marker protein from the vacuole to the Golgi. Cells lacking Svp1p accumulate abnormally large amounts of PtdIns(3,5)P2. These observations identify Svp1p as a PtdIns(3,5)P2 effector required for PtdIns(3,5)P2-dependent membrane recycling from the vacuole. Other Svp1p-related proteins, including human and Drosophila homologues, bind PtdIns(3,5)P2 similarly. Svp1p and related proteins almost certainly fold as beta-propellers, and the PtdIns(3,5)P2-binding site is on the beta-propeller. It is likely that many of the Svp1p-related proteins that are ubiquitous throughout the eukaryotes are PtdIns(3,5)P2 effectors. Svp1p is not involved in the contributions of FAB1/PtdIns(3,5)P2 to MVB sorting or to vacuole acidification and so additional PtdIns(3,5)P2 effectors must exist.

Analysis of fish ZP1/ZPB homologous genes--evidence for both genome duplication and species-specific amplification models of evolution

The vertebrate egg envelope is composed of a family of related proteins, the zona pellucida (ZP) proteins, which are characterized by the presence of a conserved zona pellucida domain. Analysis of teleost fish ZP gene sequences has demonstrated that there are no direct orthologues of the mammalian ZPB and ZP1 genes, but that teleost fish contain multiple copies of two classes of genes (ZPXa and ZPXb) that are equally related to ZPB and ZP1. The two classes of genes are further distinguished by expression in liver or ovary, respectively, indicating there was probably an initial duplication event, followed by a switch to hepatic expression of one of the paralogues. This switch was followed in some species by additional amplification of one of the paralogues with the subsequent loss of the other. It is proposed that the expansion of the number of ZPXa and ZPXb genes and the acquisition of dual sites of synthesis are the result of an ancient polyploidization event, followed by additional species-specific gene amplifications.

Vac14 controls PtdIns(3,5)P(2) synthesis and Fab1-dependent protein trafficking to the multivesicular body

BACKGROUND

The PtdIns3P 5-kinase Fab1 makes PtdIns(3,5)P(2), a phosphoinositide essential for retrograde trafficking between the vacuole/lysosome and the late endosome and also for trafficking of some proteins into the vacuole via multivesicular bodies (MVB). No regulators of Fab1 were identified until recently.

RESULTS

Visual screening of the Eurofan II panel of S. cerevisiae deletion mutants identified YLR386w as a novel regulator of vacuolar function. Others recently identified this ORF as encoding the vacuolar inheritance gene VAC14. Like fab1 mutants, yeast lacking Vac14 have enlarged vacuoles that do not acidify correctly. FAB1 overexpression corrects these defects. vac14Delta cells make very little PtdIns(3,5)P(2), and hyperosmotic shock does not stimulate PtdIns(3,5)P(2) synthesis in the normal manner, implicating Vac14 in Fab1 regulation. We also show that, like fab1Delta mutants, vac14Delta cells fail to sort GFP-Phm5 to the MVB and thence to the vacuole: irreversible ubiquitination of GFP-Phm5 overcomes this defect. In the BY4742 genetic background, loss of Vac14 causes much more penetrant effects on phosphoinositide metabolism and vacuolar trafficking than does loss of Vac7, another regulator of Fab1. Vac14 contains motifs suggestive of a role in protein trafficking and interacts with several proteins involved in clathrin-mediated membrane sorting and phosphoinositide metabolism.

CONCLUSIONS

Vac14 and Vac7 are both upstream activators of Fab1-catalysed PtdIns(3,5)P(2) synthesis, with Vac14 the dominant contributor to the hierarchy of control. Vac14 is essential for the regulated synthesis of PtdIns(3,5)P(2), for control of trafficking of some proteins to the vacuole lumen via the MVB, and for maintenance of vacuole size and acidity.

Functional genomics in reproductive medicine

The British Fertility Society organised a workshop on Functional Genomics in Reproductive Medicine at the University of Birmingham on 13-14 September 2001. The primary aim was to inform delegates about the power of the technology that has been made available after completion of the sequencing of the human genome, and to stimulate debate about using functional genomics to address both clinical and scientific questions in reproductive medicine. Three specific areas were addressed: proteomics, gene expression and bioinformatics. Although the sophistication and plethora of techniques available were obvious, major limitations in the technology were also discussed. The future promises to be very challenging indeed.

Alternative splicing of the human VEGFGR-3/FLT4 gene as a consequence of an integrated human endogenous retrovirus

The vascular endothelial growth factor receptor 3 (VEGFR-3/FLT4) is a receptor tyrosine kinase that regulates angiogenesis and vasculogenesis in response to the binding of the ligands VEGF-C and VEGF-D. Mutations in VEGFR-3 have been identified in patients with primary lymphoedema. It has been noted previously that whilst in the mouse there is only a single Vegfr-3 transcript, in humans there are two transcripts of 5.8 and 4.5 kb, of which the shorter encodes a protein that lacks the C-terminal 65 amino acids. These two isoforms also differ in their biological activity. Analysis of the human VEGFR-3 cDNA and genomic sequence reveals that these two isoforms arise by alternative splicing of the terminal exons. The shorter transcript is generated by splicing into the long terminal repeat of a human endogenous retrovirus located between the last two exons, thus explaining the lack of the shorter transcript in the mouse. The retention of the retroviral sequences in the FLT4 locus suggests that this retrotransposition event has contributed significant additional function to this gene. This provides support for a role for integrated retroviruses in modulating gene activity and participating in evolutionary processes.

The impact of managed care on children's access, satisfaction, use, and quality of care

OBJECTIVE

To examine the impact of managed care on children's access, satisfaction, use, and quality of care using nationally representative household survey data.

DATA SOURCE

The 1996 Medical Expenditure Panel Survey (MEPS).

STUDY DESIGN

Bivariate and multivariate analyses are used to detect independent effects of managed care on access, satisfaction, utilization, and quality of pediatric health services.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained from rounds 1, 2, and 3 of the 1996 MEPS. MEPS collects data on health care use, insurance, access, and satisfaction, along with basic demographic and health status information for a representative sample of the U. S. civilian, noninstitutionalized population. Our sample consists of 5,995 children between the ages of 0 and 17.

FINDINGS

Among the 18 outcome indicators examined, the bivariate analysis revealed only three statistically significant differences between children enrolled in managed care and children in traditional health plans: children enrolled in managed care were more likely to receive physician services, more likely to have access to office-based care during evening or weekend hours, and less likely to report being very satisfied with overall quality of care. However, after controlling for confounding factors, none of these differences remained statistically significant.

CONCLUSIONS

Our findings suggest that there are no statistically significant differences in self-reported outcomes for children enrolled in managed care and traditional health plans. This conclusion is provisional, however, because of limitations in the data set.

A simple diagnostic index for asthma

BACKGROUND

Asthma is becoming increasingly prevalent and a number of research groups are investigating its genetic and environmental basis.

OBJECTIVE

To produce a brief screening tool suitable for determining phenotype in asthma research.

METHODS

The scores from eight questions on symptoms and history were obtained from 678 adults and 244 children from high asthma-incidence caucasian families. An independent physician diagnosis was also obtained with the use of a modified NHLBI-CSGA questionnaire and pulmonary function test. Stepwise logistic regression was applied to determine which of the eight questions had greatest predictive value for asthma, and the quality of the resultant models was evaluated using an independent set of 643 adults and 239 children.

RESULTS

For adults, the most parsimonious model used responses from three of the eight questions. It had sensitivity and specificity of 0.94 and 0.96, respectively. For children, responses to two questions gave a model with sensitivity and specificity of 0.97. For both age groups, negative predictive values were above 0.87. Positive predictive values were 0.58 and 0.78 for adults and children respectively. The latter emphasize the need for conformation, by physician, of "affected" calls made by this initial screen.

CONCLUSION

The brief questionnaires described are potentially useful in a research setting, as a preliminary screening mechanism of low cost. Their use will reduce the numbers of subjects that must undergo detailed phenotyping.

The unmet health needs of America's children

OBJECTIVE

Unmet need for health care is a critical indicator of access problems. Among children, unmet need for care has special significance inasmuch as the failure to obtain treatment can affect health status and functioning in the near- and long-term. The purpose of this study was to present current prevalence estimates and descriptive characteristics of children with unmet health needs using nationally representative household survey data.

METHODS

We analyzed 4 years of National Health Interview Survey data spanning 1993 through 1996. Our analysis included 97 206 children <18 years old. Measures of unmet need for medical care, dental care, prescription medications, and vision care were obtained from an adult household member (usually the mother) responding for the child. Bivariate and multivariate analyses were used to assess the degree to which unmet need was related to the demographic and socioeconomic characteristics of the child and family.

RESULTS

Overall, 7.3% (4.7 million) of US children experienced at least 1 unmet health care need. Dental care was the most prevalent unmet need. After adjustment for confounding factors, near-poor and poor children were both about 3 times more likely to have an unmet need as nonpoor children (adjusted odds ratio [95% confidence interval] = 2.89 [2.52, 3.32], 3.0 [2.53, 3.56], respectively). Uninsured children were also about 3 times more likely to have an unmet need as privately insured children (adjusted odds ratio [95% confidence interval] = 2. 92 [2.58, 3.32]).

CONCLUSIONS

Despite the nation's great wealth, unmet health needs remain prevalent among US children. A combined public policy that addresses financial and nonfinancial barriers to care is required to reduce the prevalence of unmet need for health care.

Impact of correlated factors on bone density in individuals with a family history of osteoporosis

Previous studies have suggested that 14-47% of the variation in bone mineral density (BMD) can be predicted using clinical risk factors. The aim of our study was to determine, for the first time, the importance of these factors in individuals with evidence of a genetic predisposition to the disease. The subjects studied were 147 female and 86 male Caucasians, all with a family history of osteoporosis. Linear regression was used to determine whether age, height, weight, and years of reduced estrogen exposure were significant predictors of BMD. Males and females were examined separately, and BMD was measured at the hip and spine. The results show that these risk factors, known to be at work in the general population, are equally important in those with a family history of osteoporosis. It is clear, therefore, that they must be taken into account, and corrected for in genetic studies of the disease.

Identification of the true human orthologue of the mouse Zp1 gene: evidence for greater complexity in the mammalian zona pellucida?

The mammalian zona pellucida is a mixture of glycoproteins, believed to be encoded by three distinct genes, ZP1/ZPB, ZP2/ZPA, and ZP3/ZPC. We have now determined that the true human orthologue of the mouse Zp1 gene is not ZPB, but that there is a distinct human ZP1 gene. Comparison of the human ZP1 and murine Zp1 genes indicates significant conservation of nucleotide and amino acid sequences, of intron-exon size and organisation, and of regulatory sequences. In addition, the mouse and human ZP1 genes are in a region of conserved synteny between human chromosome 11 and mouse chromosome 19.

Functional impairment and utilization of services associated with posttraumatic stress in the community

This study describes social functioning and service utilization patterns associated with posttraumatic stress symptoms relative to nonpsychiatric controls and depressive disorder controls in a cross-sectional epidemiological survey. Data from 49 cases and 147 controls who participated in the North Carolina component of the Epidemiologic Catchment Area study were examined. Results indicate that symptoms of posttraumatic stress were associated with impairment along several domains of functioning: social, financial, physical, and psychological. Individuals with posttraumatic stress were found to have more socioeconomic disadvantages and impaired functioning. Despite this, individuals with posttraumatic stress are receiving relatively few mental health services. Further research assessing service use, treatment, and functional outcomes are indicated.

The role of Medicaid in ensuring children's access to care

CONTEXT

Congress enacted a series of laws beginning in the mid 1980s to expand Medicaid eligibility for children, especially those in poor families. As a result, Medicaid enrollment of children has nearly doubled over the past decade.

OBJECTIVE

To assess the effectiveness of Medicaid in improving access to and use of health services by poor children.

DESIGN

Analysis of cross-sectional survey data from the 1995 National Health Interview Survey. Poor children with Medicaid were compared to poor children without insurance and nonpoor children with private insurance.

SETTING AND PARTICIPANTS

A total of 29711 children younger than 18 years (3716 poor children with Medicaid, 1329 poor children without insurance, 14609 nonpoor children with private insurance, and 10057 children with other combinations of poverty and insurance status) included in a nationally representative stratified probability sample of the US noninstitutionalized population.

MAIN OUTCOME MEASURES

Usual source of care, access to a regular clinician, unmet health needs, and use of physician services.

RESULTS

Poor children with Medicaid compared to poor children without health insurance experienced superior access across all measured dimensions of health care, including presence of a usual source of care (95.6% vs 73.8%), frequency of unmet health needs (2.1 % vs 5.9%), and use of medical services (eg, > or =1 physician contact in past year) (83.9% vs 60.7%). Poor children with Medicaid compared to nonpoor children with private insurance used similar levels of physician services (83.9% vs 84%), but were more likely to have unmet health needs (2.1 % vs 0.6%) and were less likely to have a usual source of care (95.6% vs 97.4%).

CONCLUSION

Medicaid is associated with improvements in access to care and use of services. However, there remains room for improvement when Medicaid is judged against private health insurance. The Balanced Budget Act of 1997 contains several Medicaid provisions that could stimulate further improvements in access for poor children.

Evaluating community efforts to decategorize and integrate financing of children's health services

Publicly funded categorical programs for children often differ in eligibility rules, allowable services, and criteria for provider participation, making it necessary for families to navigate through several programs to piece together care for their children. Recognizing these problems, the Robert Wood Johnson Foundation launched a national demonstration project in 1991 with the goal of decategorizing children's health services in nine communities. It was hoped that by releasing funds from categorical restrictions on their use, scarce public resources could be directed where they might have the greatest impact. However, the demonstration sites confronted a number of challenges in designing and implementing decategorization strategies: an absence of existing models and effective technical assistance; political hurdles in gaining cooperation from the multiple local agencies engaged in service provision; and difficulties in carrying out major programmatic changes when the health care system itself was rapidly being transformed. The proposition that decategorization holds promise as a tool for improving access to health care deserves further investigation.

Mutations in the human alpha-tectorin gene cause autosomal dominant non-syndromic hearing impairment

The tectorial membrane is an extracellular matrix of the inner ear that contacts the stereocilia bundles of specialized sensory hair cells. Sound induces movement of these hair cells relative to the tectorial membrane, deflects the stereocilia, and leads to fluctuations in hair-cell membrane potential, transducing sound into electrical signals. Alpha-tectorin is one of the major non-collagenous components of the tectorial membrane. Recently, the gene encoding mouse alpha-tectorin (Tecta) was mapped to a region of mouse chromosome 9, which shows evolutionary conservation with human chromosome 11q (ref. 3), where linkage was found in two families, one Belgian (DFNA12; ref. 4) and the other, Austrian (DFNA8; unpublished data), with autosomal dominant non-syndromic hearing impairment. We determined the complete sequence and the intron-exon structure of the human TECTA gene. In both families, mutation analysis revealed missense mutations which replace conserved amino-acid residues within the zona pellucida domain of TECTA. These findings indicate that mutations in TECTA are responsible for hearing impairment in these families, and implicate a new type of protein in the pathogenesis of hearing impairment.

The use of formative evaluation to assess integrated services for children. The Robert Wood Johnson Foundation Child Health Initiative

This article describes the use of formative evaluation in assessing the feasibility of implementing a new service integration effort. The Child Health Initiative, a nine-site, national demonstration project funded in 1991 by the Robert Wood Johnson Foundation, sought to implement systemic change through the creation of new mechanisms for spending service dollars more flexibly at the local site. The Child Health Initiative called for developing local child health-monitoring systems, a care coordination mechanism, and a program for decategorizing the myriad of restrictive categorical public programs serving children. Most demonstration communities experienced some degree of success in achieving the first two components, but none was able to implement decategorization during the 3- to 5-year funding period. Key lessons for evaluators include the need for (a) a flexible evaluation design that can sequentially adapt to changes in program implementation, (b) repeated longitudinal data collection measures to document changes over time, (c) avoidance of a premature focus on program outcomes, and (d) methods to establish attribution of outcomes.

Health insurance and access to primary care for children

BACKGROUND

Numerous studies have demonstrated that insurance status influences the amount of ambulatory care received by children, but few have assessed the role of insurance as a determinant of children's access to primary care. We studied the effect of health insurance on children's access to primary care.

METHODS

We analyzed a sample of 49,367 children under 18 years of age from the 1993-1994 National Health Interview Survey, a nationwide household survey. The overall rate of response was 86.5 percent. The survey included questions on insurance coverage and access to primary care.

RESULTS

An estimated 13 percent of U.S. children did not have health insurance in 1993-1994. Uninsured children were less likely than insured children to have a usual source of care (75.9 percent vs. 96.2 percent, P<0.001). Among those with a usual source of care, uninsured children were more likely than insured children to have no regular physician (24.3 percent vs. 13.8 percent, P<0.001), to be without access to medical care after normal business hours (11.8 percent vs. 7.1 percent, P<0.001), and to have families that were dissatisfied with at least one aspect of their care (19.6 percent vs. 14.0 percent, P=0.01). Uninsured children were more likely than insured children to have gone without needed medical, dental, or other health care (22.2 percent vs. 6.1 percent, P<0.001). Uninsured children were also less likely than insured children to have had contact with a physician during the previous year (67.4 percent vs. 83.8 percent, P<0.001). All differences remained significant after we controlled for potential confounders using linear and logistic regression.

CONCLUSIONS

Among children, having health insurance is strongly associated with access to primary care. The new children's health insurance program enacted as part of the Balanced Budget Act of 1997 may substantially improve access to and use of primary care by children.

Mapping of the alpha-tectorin gene (TECTA) to mouse chromosome 9 and human chromosome 11: a candidate for human autosomal dominant nonsyndromic deafness

alpha-Tectorin is one of the major noncollagenous components of the mammalian tectorial membrane in the inner ear. We have mapped the gene encoding alpha-tectorin to mouse chromosome 9 and human chromosome 11 in a known region of conserved synteny. Human YAC clones containing alpha-tectorin have been identified, demonstrating physical linkage to the anonymous marker D11S925. This places alpha-tectorin within the genetic interval that contains both the human nonsyndromic autosomal dominant deafness DFNA12 and the proximal limit of a subset of deletions within Jacobsen syndrome. Thus both DFNA12 and the hearing loss in some cases of Jacobsen syndrome may be due to haploinsufficiency for TECTA.

Managed care and children: an overview

This article lays the foundation for the other articles in this journal issue, which examine the effect of managed health care arrangements on a particular population: children. Although managed care has been used to finance and deliver health care services for decades, the meaning of this term often has been unclear to health care consumers and practitioners because new forms of managed care have evolved rapidly. The one consistent and unifying concept across all managed care arrangements is that enrollees obtain care from a network of participating health care providers who contract with the managed care organization and abide by the organization's rules. The uncertainty of what managed care is has made it difficult to measure the effect of these arrangements on health service delivery and health outcomes, especially in the pediatric population, where the development of outcome and quality measures lags behind that for adults. The incentives posed by managed care suggest both potential advantages and disadvantages to these arrangements for children. On the positive side, managed care enrollment may offer a "medical home" for primary care services to children who otherwise would obtain only episodic care; improve the coordination of health care services; and encourage more preventive health services. On the negative side, under capitated reimbursement, health plans have an incentive to enroll only healthy children with the lowest expected health care expenditures, and providers have an incentive to offer fewer services than may be appropriate. Managed care also may limit enrollees' choice of providers, particularly for specialty care. Despite the paucity of information about the effect of managed care on the delivery of pediatric health services and on child health outcomes, children are disproportionately being enrolled in managed care plans.

Integrating children's health services: evaluation of a national demonstration project

OBJECTIVES

Increasingly, the public and private sectors are turning to "service integration" efforts to reduce, if not eliminate, barriers to needed care created by categorical programs. In 1991, the Robert Wood Johnson Foundation established a new national demonstration project, called the Child Health Initiative, intended to test the feasibility of developing mechanisms at the community level to coordinate the delivery of health services and to pay for those services through a flexible pool of previously categorical funds. This article presents the findings of an independent evaluation of the Child Health Initiative.

METHOD

The evaluation utilized a combination of qualitative methods to assess and describe the experiences of the communities as they developed and implemented integrated health services. It used a repeated measures design involving two site visits and interim telephone interviews, as well as review of documents.

RESULTS

Overall, the demonstration project achieved mixed success. Both care coordination and the production of community health report cards were found to be achievable within the relatively short life of the foundation grant. However, many sites experienced significant delays in the production of report cards and implementing care coordination plans because the sites largely did not benefit from the successful models already in existence. Little clear progress was made in implementing the decategorization component of the project. Sites experienced difficulties due to lack of previous experience with this new undertaking, the inability to secure active cooperation from local, state, and federal agencies, the relatively short duration of the project, and other factors.

CONCLUSIONS

A number of lessons were learned from this project that may be useful in future decategorization experiments, including (1) a clear understanding of the concept and its applications among all parties is essential, (2) high-level political commitments to the effort are needed between all levels of government, (3) adequate technical assistance should be provided to surmount technical considerations in establishing a workable approach to decategorization, and (4) decategorization and service integration efforts should focus on both the health and social sectors.

Social HMOs and other capitated arrangements for children with special health care needs

OBJECTIVE

Children with special health care needs are increasingly enrolling in managed care arrangements. However, existing managed care organizations, including traditional HMOs, are often poorly suited for caring for this population. In the adult health care area, new managed care entities, called Social HMOs (S/HMO) and Programs for the All-inclusive Care for the Elderly (PACE), have been created to integrate health and health-related services for chronically ill and disabled adults. We describe these models and assess their potential for serving children with special health care needs.

METHOD

We reviewed the literature on managed care for children with special health care needs and evaluation findings from the S/HMO and PACE models for the elderly.

RESULTS

Evaluations of the S/HMO and PACE models have yielded mixed findings. Some of the more positive accomplishments include lower use and expenditures for long-term care services compared to other demonstration projects, greater integration of primary care physicians in decision making concerning long-term care, and improved management of transitions between care levels. On the negative side, start-up has been slow, prospective members have been hesitant to enroll, intermittent and sometimes frequent operating deficits have emerged, no discernible positive effects on health or social outcomes are apparent, and no significant overall savings have emerged.

CONCLUSIONS

With mixed results so far, caution is required in applying these or similar models for vulnerable child populations. However, given the inadequacies of traditional managed care for this population, we believe experimentation with new models of care that integrate health and health-related services is important. Such experimentation should be fostered only to the extent that the models are carefully designed and then implemented in a manner that protects the interests of children with special health care needs.

Cloning and sequencing of the mouse Gli2 gene: localization to the Dominant hemimelia critical region

The GLI family of zinc finger genes has been implicated in both neoplastic and developmental disorders. We have cloned and sequenced the mouse homolog of the zinc finger gene Gli2 and demonstrated significant similarity to the human GLI3 gene. We have also localized Gli2 to mouse chromosome 1, in the vicinity of the morphogenetic mutation Dominant hemimelia (Dh), which is characterized by tibial hemimelia, poly/oligodactyly, and a number of visceral abnormalities, most strikingly absence of the spleen. Using a Gli2-associated microsatellite, we demonstrated no recombination between Dh and Gli2 in a Dh intraspecific backcross. Gli2 is expressed in Dh heterozygotes and homozygotes. However, using a combination of mismatch analysis and direct sequencing, we have failed to identify any mutations in the coding sequence of Gli2 from Dh. We have also demonstrated that it is unlikely that there are any Gli genes in the mouse genome in addition to the previously described Gli, Gli2, and Gli3.

Paradigms and paradoxes: mouse (and human) models of genetic deafness

Mouse models have proved valuable tools in the analysis of human genetic disorders. The identification of the genes mutated in classical mouse mutants and the analysis of the phenotype of mutants following targeted gene disruption have provided some clarification of the development and functioning of the inner ear. A number of these genes also play a role in human deafness. Analysis of mutations in both human and mouse deafness genes has identified a number of distinct phenomena that contribute to the observed phenotype.

The association of sexual assault and attempted suicide within the community

BACKGROUND

Lifetime community rates of attempted suicide were compared between those who reported a history of sexual assault and a control group without such a history.

METHODS

The 2918 respondents in the Duke University Epidemiological Catchment Area Study were placed into groups with reported sexual assault (n = 67) and those with no known history of such (n = 2851). Multivariate and bivariate procedures were used to examine the relation between sexual assault and attempted suicide.

RESULTS

Subjects reporting a history of sexual assault were more likely to be female, younger, and to report higher rates of lifetime suicide attempt and post-traumatic stress symptoms; no differences were found in the number of chronic medical disorders, major depression, substance abuse or substance dependence, or panic attacks. Nine (14.9%) of the 67 index group subjects reported a suicide attempt, 4 of whom reported their first sexual assault as occurring before age 16 years. A sexual assault history was associated with increased prevalence of lifetime suicide attempt after controlling for sex, age, education, posttraumatic stress symptoms, and psychiatric disorder. Findings were similar in the female-only subsample (n = 1778). For women, the odds of attempting suicide was 3 to 4 times greater when the first reported sexual assault occurred prior to age 16 years compared with age 16 years or older.

CONCLUSIONS

Sexual assault is associated with an increased lifetime rate of attempted suicide. In women, a history of sexual trauma before age 16 years is a particularly strong correlate of attempted suicide.

Children's access to primary care: differences by race, income, and insurance status

OBJECTIVE

Congressional initiatives to reduce spending under major public programs designed to improve access to health care have brought renewed attention to the health care needs of traditionally disadvantaged populations. The objective of this study was to assess access to and use of primary care services for poor, minority, and uninsured children in the United States.

DESIGN AND SETTING

We analyzed data on 7578 1- to 17-year-old children of families responding to the 1987 National Medical Expenditure Survey, a nationally representative sample of families and children.

OUTCOME MEASURES

Adult respondents were asked to report on several measures of access and use of care for children in the household. These included the presence of a usual source of care and its characteristics (type of site, travel time, waiting time, after-hours care, and availability of a regular physician). We also examined the volume of physician contacts relative to the sample child's health status, the receipt of measles vaccinations, and whether children received care in response to selected symptoms of ill health. Results are presented for children generally and for four subgroups: poor children; minority children; uninsured children; and white, non-poor, insured children (the reference group).

RESULTS

Poor, minority, and uninsured children fared consistently worse than the children in the reference group on all indicators studied. For example, children in each of the three at-risk groups were twice as likely as the children in the reference group to lack usual sources of care, nearly twice as likely to wait 60 minutes or more at their sites of care, and used only about half as many physician services after adjusting for health status. Multivariate analyses revealed that poverty, minority status, and absence of insurance exert independent effects on access to and use of primary care.

CONCLUSIONS

The existence of substantial barriers to the access to and use of primary care for low-income, minority, and uninsured children is cause for significant concern, especially in an era of program cutbacks. New initiatives are needed to address both financial and non-financial barriers to the receipt of primary care for disenfranchised children.

Improving children's access to health care: the role of decategorization

Far too many children in this country are unable to obtain the health care they need because of barriers that prohibit easy access. Among the most significant obstacles are financial barriers, including lack of adequate health insurance and inadequate funding of programs for low-income children and those with special health-care needs. Another set of "non-financial" barriers are related to the categorical nature of addressing children's health-care needs, which impedes access by increasing the complexity and burden of seeking care and discourages providers from providing care. Decategorization represents an appealing partial remedy to these problems because it can lead to fundamental and lasting changes in financing and delivering health services. The greatest appeal of decategorization is its potential to improve access to care with the expenditure of little or no new funds. Decategorization also holds considerable risk. Depending on how it is designed and implemented, decategorization may lead to diminished access to care by serving as a foil for budget cuts or by undermining essential standards of care. However, these risks do not negate the value of exploring decategorization as an approach that can be taken today to better organize services and ensure that existing resources adequately meet children's needs. In this report we examine the role of decategorization as a mechanism for removing the barriers to care that are created by categorical funding of health programs.

Prenatal care and public policy: lessons for promoting women's health

One of the most notable health-related legislative achievements of the 1980s was the expansion that transformed Medicaid from a medical assistance program for a relatively small group of the very poorest mothers meeting strict categorical criteria to a health program for low-income uninsured, pregnant women and their children, regardless of work status or family composition. Yet Medicaid coverage remains unavailable to millions of poor and uninsured women who are significantly less likely to obtain needed care without health insurance. Among the factors that help explain why Medicaid was not simultaneously expanded for uninsured women are our nation's longstanding reluctance to provide public assistance except to individuals deemed "deserving" based on the circumstances that led to their indigency. Another factor is the special value our culture places on pregnancy, which permits pregnant women who do not meet the definitions of the "deserving" to transcend those restrictions. Finally, while data served as an effective tool in the campaign for pregnant women's coverage, comparable data related to nonpregnant women are limited. Nonetheless, the lessons from the Medicaid expansion are helpful in efforts to improve women's access to care in general.

A screen for RAS mutations in individuals at risk of secondary leukaemia due to occupational exposure to petrochemicals

Occupational exposure to petrochemicals, in particular benzene, has been identified as a risk factor in the development of acute leukaemia. A cohort of exposed (n = 44) and non-exposed individuals (n = 19) from the same petrochemical installation were screened by polymerase chain reaction (PCR) followed by oligonucleotide hybridization (ONH) for the presence of mutations in the H, K, and NRAS cellular proto-oncogenes. A KRAS mutation was detected in one individual from the exposed group who was haematologically normal at the time of sampling. The presence of this mutation was confirmed by nude mouse tumorigenicity assay and positively identified as a K13 Gly-Asp substitution by cloning and sequencing.

Decategorizing health services: interim findings from the Robert Wood Johnson Foundation's Child Health Initiative

Although results from the evaluation are preliminary thus far, certain tentative conclusions can be reached. First, both care coordination on a small scale and the production of community health report cards are achievable within the relatively short life of a foundation grant. Moreover, both efforts can result in tangible improvements for children and their families. Report cards associated with the initiative have made children's issues more prominent and appear to have led many community leaders to focus greater attention on children's needs. Likewise, many of the care coordination systems developed under the initiative have produced real change for children and their families by guiding them to needed health care and other services. It is important, however, to keep these accomplishments in perspective. While of significant benefit to demonstration communities, the monitoring and care coordination components of this initiative are not unique. A large number of communities have adopted monitoring and reporting programs in recent years. Similarly, care coordination efforts are well established in many communities. What is unique about the RWJF initiative is its attempt at decategorization, and much less progress has been demonstrated for this component. The less-than-hoped-for progress in implementing decategorization at the original sites appears to be the product of a number of interrelated factors. These include an absence of existing models and appropriate technical assistance; political difficulties in gaining cooperation from multiple local agencies involved in service provision; limited progress in establishing needed connections with the state and federal agencies that have authority over categorical programs; and difficulties in implementing major programatic changes when the health care system itself is undergoing rapid change. In combination, these barriers have proven to be largely insurmountable for the originally funded sites, although it is too early in the project to determine which of these factors is predominantly responsible for the lack of success. Whether the newer sites can learn from the experience of the first group and adapt strategies to overcome the multiple hurdles involved remains to be seen. Decategorization is a tool that has the potential to rationalize a fragmented service system by facilitating the coordination of services, especially for children and families with multiple needs. The need for decategorization of funds will not disappear, even if the federal government chooses to combine more of its grant programs to the states into block grants.(ABSTRACT TRUNCATED AT 400 WORDS)

Children and health insurance: an overview of recent trends

This DataWatch examines trends in health insurance coverage of children using recent data from the Current Population Survey. The results indicate that the number and proportion of children who were uninsured changed little between 1988 and 1992. However, substantial changes occurred in the composition of the insured population: The proportion of children covered by employer-based private insurance declined from 60.7 percent in 1988 to 56.2 percent in 1992, while the proportion of children covered by Medicaid increased from 15.6 percent to 21.6 percent over the same period. These results indicate that a fundamental shift is occurring in responsibility for insuring the nation's children--from the private sector to the public sector.

The boundary of social phobia. Exploring the threshold

BACKGROUND

Individuals with subthreshold social phobia (SSP) in the community are characterized relative to nonphobic, healthy controls (C), and diagnosed social phobics (SP).

METHODS

Data from 1488 subjects from the Duke University Epidemiological Catchment Area Study were examined. Bivariate and multivariate methods were used to compare the SSP, SP, and C groups on 10 sets of variables.

RESULTS

Compared with C respondents, SSP respondents were more likely to be female and unmarried and to report less income and education. The SSP respondents were also more likely to report work attendance problems, poor grades in school, symptoms of conduct disturbance, impaired subjective social support, lack of self-confidence, lack of a close friend, use of psychotropic drugs in past year, and a greater number of life changes, chronic medical problems, and mental health visits within the past 6 months. In a multivariate logistic regression model with group membership as the dependent variable, compared with C respondents, SSP respondents were more likely to be female, to have less education, and to report more indicators of poor school performance and symptoms of adolescent conduct disturbance. In contrast, in a similar but separate multivariate model, compared with SP respondents, SSP respondents met the criteria for fewer DSM-III psychiatric disorders and were less likely to report impaired instrumental support.

CONCLUSION

Social phobia adversely affects over 10% of the population. Previous epidemiologic catchment area-based prevalence estimates have probably been unrealistically low.

Does age make a difference in the effects of physical health and social support on the outcome of a major depressive episode?

OBJECTIVE

The authors examined the effects of physical health and social support on 6-month outcome of a major depressive episode in 67 patients who were less than 60 years old and 46 patients who were 60 years old or older. They hypothesized that despite their higher rate of troublesome health problems, older patients would have fewer depressive symptoms at follow-up than would younger patients.

METHOD

The Center for Epidemiologic Studies Depression Scale (CES-D Scale) and a modified version of the National Institute of Mental Health Diagnostic Interview Schedule were used to gather data from inpatients and outpatients treated at Duke University Medical Center during a face-to-face interview at baseline and over the telephone at 6-month follow-up. At baseline, all patients met DSM-III-R criteria for a major depressive episode. Data analyses included bivariate and multivariate procedures.

RESULTS

At baseline, the mean CES-D Scale scores of the two age groups were similar. As expected, the mean illness index score of the older patients was significantly higher and their mean impaired subjective social support score was slightly lower than those of the younger patients. At 6-month follow-up, the mean CES-D Scale score of the younger patients was above the depressive threshold, but the mean CES-D Scale score of the older patients was below the depressive threshold. The illness index and impaired subjective support measures were significant predictors of depressive symptoms at 6 months for the younger patients but not for the older patients.

CONCLUSIONS

The authors conclude that older depressed patients have a more favorable prognosis than younger depressed patients. Predictors of outcome vary by age.

Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals

The 35-item Duke Social Support Index (DSSI) measures multiple dimensions of social support and has been used extensively in cross-sectional and longitudinal studies of aging. Epidemiological studies of chronically ill, frail elderly individuals often wish to include a measure of social support. However, most multidimensional measures (including the DSSI) are long and may exhaust the patient, especially when included in an often already congested interview schedule. The authors have developed two abbreviated versions of the DSSI (23-item and 11-item) that capture the essential components of social support related to mental health outcomes and use of health services in treating elderly individuals with nonpsychiatric medical illness.

Religious affiliation and major depression

Data from the Duke Epidemiologic Catchment Area survey were used to examine the relationship between religious affiliation and major depression among 2,850 adults in the community. Religious affiliations were categorized into six groups: mainline Protestant (27 percent), conservative Protestant (59 percent), Pentecostal (4.2 percent), Catholic (2.4 percent), other religions (2.6 percent), and no affiliation (4.4 percent). The six-month prevalence of major depression among Pentecostals was 5.4 percent, compared with 1.7 percent for the entire sample. Even after psychosocial factors such as gender, age, race, socioeconomic status, negative life events, and social support were controlled for, the likelihood of major depression among Pentecostals was three times greater than among persons with other affiliations. Carefully designed studies are needed to understand the complex interactions of religion and mental health.