Nasal route for infant resuscitation by mothers

In infants under 6 months of age air normally enters the trachea by the nose because the tongue fills the oral cavity, and the oral route is open only when the infant is making muscular efforts such as crying or gasping. The present recommendation for infant resuscitation is for the resuscitator's mouth to cover the mouth and nose of the baby. We set out to test whether this recommendation is feasible. We measured the dimensions of the faces of 28 babies aged between 2 and 4 months (the age when resuscitation is most often needed) and of the mouths of 25 of their mothers. Only 2 mothers would have been able to cover with their mouths the nose and closed mouth of 2 babies (not their own). The mannequins often used to teach adults to resuscitate infants are misleading because they present a wide open mouth, thus implying that that is the preferred route. We recommend that the nasal route of air entry be taught to parents for resuscitation of babies who have stopped breathing.

Integrating patient satisfaction with a quality improvement program

Meeting and exceeding customers' expectations is the heart of any quality improvement program. The authors describe the development of a survey tool designed to assess patient satisfaction and its role in the hospital's total quality management initiative.

Serum growth hormone-binding protein (GHBP) in domestic animals as measured by ELISA

This research was conducted to develop and characterize a competitive ELISA for bovine serum growth hormone-binding protein (GHBP) using recombinant bovine GHBP and a polyclonal rabbit antiserum. In addition to bovine, however, the assay was found to measure some activity in equine, chicken, porcine, ovine, and human sera. The reference standard curve had an effective range of 3 to 200 ng/mL. Recovery of increasing amounts of GHBP added to ovine serum was 103% but seemed to overestimate the amount of GHBP at low concentrations (intercept = 2.5 ng/mL). Recovery from bovine and porcine serum was near ideal but seems to be overestimated at concentrations higher than 50 ng/microL. Within and between assay coefficients of variation were 12.1 and 18.9%, respectively, for a sheep serum pool. Neither exogenous GH (20 ng/mL) nor prolactin (100 ng/mL) interfered with the measurement of GHBP in serum. The GHBP activity measured in increasing doses of serum from ovine, porcine, and bovine inhibited the assay in a parallel manner. This observation suggests that the GHBP antiserum contains antibodies that are directed toward epitopes of GHBP, which are common among these species. Serum GHBP concentrations were similar among samples from a line of miniature Brahman and normal stature Brahman and Angus cattle. In mature ewes, there were no differences in serum GHBP among three different breed types. An increase (P < .0001) in serum GHBP was observed in pigs between 1 and 6 mo of age but no sex effect was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Upper airway radiographs in infants with upper airway insufficiency

Upper airway measurements in nine infants considered to be at risk of upper airway insufficiency, six of whom presented after an apnoeic episode, were compared with measurements taken in two age groups of healthy infants. Paired, inspiratory and expiratory, lateral upper airway radiographs were obtained while the infants were awake and breathing quietly. The radiographs of all nine infants demonstrated narrowing in the oropharyngeal portion of the airway during inspiration and in six infants there was ballooning of the upper airway during expiration. Seven of the nine infants subsequently experienced recurrent apnoeic episodes which required vigorous stimulation to restore breathing. Experience suggests that respiratory phase timed radiographs are a useful adjunct to the evaluation of infants who are suspected of having upper airway dysfunction. They provide information regarding both the dimensions and compliance of the upper airway as well as the site of any restriction.

Concentrations of thymulin in unextracted serum from pigs, sheep and cattle as measured by ELISA

These studies were conducted to develop an ELISA for measurement of thymulin concentrations in unextracted blood serum (or plasma) from domestic animal species (pigs, sheep and cows). This assay was quite variable (intraassay C.V. of 13.3 and 6.4% at 12.6 and 50.5 pg/mL and interassay C.V. of 24.2%). Serial dilutions of serum from these species produced inhibition curves parallel to the reference standard, suggesting that there were no substances in serum causing non-specific interference in the assay. In addition, none of the other thymic peptides tested resulted in problematic displacement of thymulin binding to the antiserum. Using this assay, it was found that somatotropin (ST) treatment had no effect on serum thymulin concentrations in either pigs or cows. Chromatographic separation of thymulin activity in sheep serum showed three peaks with approximate MW estimates of 95, 80 and 1 kDa. Serum thymulin concentrations in a sheep injected with thymulin was cleared from blood with a half-life (t1/2) of 10.3 +/- 0.6 min. Serum thymulin concentrations increased between birth and 6 mo old in pigs. These data indicate that a rapid and reliable ELISA has been developed to measure thymulin in blood of these domestic animals. This assay should be of value in the study of thymulin function and factors regulating its secretion.

Factors affecting circulating growth hormone binding protein in chickens

Growth hormone binding protein (GHBP) may be an important factor in the regulation of growth and might provide an indirect, relatively noninvasive means of predicting the status of hepatic growth hormone receptor (GHR) activity. Several factors have been reported to influence growth hormone (GH), GHR, or GHBP. Therefore, these studies were conducted to test how age, sex, nutritional status, and glucocorticoids (cortisone acetate, CA) influence serum concentrations of chicken GHBP. Serum GHBP activity was highest (mean percentage specific binding (%SB) = 12.43 +/- .80) at hatch and decreased linearly (P < .0001) to 5 wk of age (%SB = 1.99 +/- 1.13). There were no sex-related differences in serum GHBP activity from hatch to 5 wk of age (P > .08). Short-term nutrient deprivation (24-h) of 4-wk-old broilers also had a significant effect on serum GHBP activity (P < .0001). Measurement of serum GHBP activity with refeeding (after a 24-h period without feed) restored %SB to normal values. Feeding broilers a low-protein diet (12% CP) did not significantly affect serum GHBP activity when compared with that of broilers fed a commercial broiler diet (23% CP; P > .30). Administration of cortisone (1, 5, and 10 mg/day), every 24 h for 7 days, had no effect, at any dose, on serum GHBP activity at 48 h and 1 wk after the last injection. These results indicate that serum GHBP activity is influenced by factors such as age and feed deprivation. It remains to be determined whether these changes in GHBP are associated with changes in GHR as reported for mammalian species.

Adult respiratory distress syndrome in children: associated disease, clinical course, and predictors of death

The adult respiratory distress syndrome is a common cause of respiratory failure; however, its incidence, risk factors, course, and mortality rate for children remain incompletely understood. A 24-month surveillance of pediatric intensive care admissions identified 60 children with adult respiratory distress syndrome constituting 2.7% of such admissions, 8% of total days spent in a pediatric intensive care unit, and 33% of deaths. The mortality rate was 62% (confidence interval, 48.2% to 73.9%). Adult respiratory distress syndrome occurred in approximately 12% of children admitted for sepsis, viral pneumonia, smoke inhalation, or drowning. A low incidence (< 3%) was observed in children admitted with pulmonary contusion or multiple trauma. Ongoing changes in measures of pulmonary gas exchange varied with the magnitude of alveolar injury; no differences were associated with the underlying acute disease or lung injury mechanism. Efficiency of oxygenation differed among outcome groups by the second day after onset of adult respiratory distress syndrome. An alveolar-arterial oxygen tension difference > 420 was the best early predictor of death (sensitivity 80%, specificity 87%, positive predictive value 87%, negative predictive value 80%, and odds ratio 26.7). We conclude that adult respiratory distress syndrome behaves clinically as a single disease regardless of the underlying cause; its course and outcome are dependent on the magnitude of alveolar injury. We speculate that strategies for minimizing secondary lung injury may benefit all patients with adult respiratory distress syndrome.

Assessment of factors regulating serum growth hormone binding protein in pigs

These studies were conducted to examine the influence of several variables on the growth hormone binding protein (GHBP) activity in serum of pigs. Continuous long-term porcine somatotropin (pST) injections (daily for 6 to 7 wk) increased GHBP activity (P less than .05). However, periodic short-term pST injections (daily, every 2nd d, or every 4th d for 2 wk) did not cause a significant change in GHBP levels (P greater than .40). Although fasting seems to reduce liver GH receptors, no difference was observed between fed animals and animals fasted for 5 d (P greater than .30). Between 0 and 6 mo of age, boar and gilt serum GHBP activity were not significantly different from each other but increased with age in both sexes (P less than .0001). There was no significant correlation between serum GHBP and BW at 6 mo of age in this study (P greater than .30). In pregnant sows, GHBP concentrations were highest at the beginning (d 72) of the third trimester (P less than .05). Growth hormone receptor activity reported by other researchers and GHBP activity in this study seem to vary similarly except during fasting, which may indicate alternate regulation of either the GHBP or the GH receptor.

Male breast carcinoma: clinical experience in a suburban community

Male breast cancer is difficult to study because it occurs infrequently, accounting for 1% of all breast carcinoma. Breast cancer occurs 10 years later in men than in women, and its presentation parallels that in women. The authors retrospectively review 13 cases of male breast cancer occurring over a 20-year period in four community hospitals. Treatment methods paralleled those used for female cancer patients. Surgery, primarily radical mastectomy, was performed in all patients. In the eight patients in whom hormone receptor assays were obtained, all tests were positive for estrogen receptors, progesterone receptors, or both. Metastases were diagnosed in five patients during follow-up. The longest disease-free survival has been 10 years. Similarities and differences regarding male and female breast cancer are discussed as are the diagnosis and management of men with this disease.

Identification and partial purification of serum growth hormone binding protein in domestic animal species

The chemical nature and variations in serum concentrations of growth hormone binding protein (GHBP) from humans, rabbits, and rodents have been reported. To date little is known about the GHBP of domestic animals. Therefore, we initiated these studies to determine whether a serum GHBP was present in domestic animals and to purify the binding protein (BP) from serum of selected species. Using a dextran-coated charcoal separation assay, specific growth hormone (GH) binding was demonstrated in ovine, bovine, chicken, human, goose, porcine, and equine serum (listed in sequence from lowest to highest binding). Variation in BP activity was relatively high, both within and between species. Yearling ewes had higher serum GHBP than either prepubertal (4 mo) or older (5 yr) ewes. The GHBP was partially purified from chicken, ovine, and porcine serum using GH affinity chromatography. These BP had high affinity (Ka = 2 x 10(8) to 2 x 10(9) L/mol, depending on species) and low capacity (2 x 10(-10) to 5 x 10(-11) mol/unit of protein) for human GH but showed lower binding affinity for homologous GH (Ka = 2 x 10(7) L/mol). The porcine GHBP had the highest and ovine GHBP the lowest affinity for human GH. Other heterologous somatotropic hormones, ovine placental lactogen, and ovine GH displayed higher binding affinity to chicken and pig BP than the respective homologous hormones. Further chromatographic purification of the porcine GHBP resulted in an additional 1,000-fold purification. The estimated molecular weight of porcine GHBP is 50,000 to 60,000 Da. These results demonstrate that the serum from all domestic species tested contains a specific GH-binding moiety and that under the conditions described here human GH is a more efficient ligand than the homologous hormone.

Response of the rabbit lung as a criterion of safety for fluorocarbon breathing and blood substitutes

From the first liquid breathing experiments until now, the lung, not surprisingly, has played a central role in the evolution of fluorocarbon blood substitutes. The first breathable fluorocarbon, a mixture of F-alkylfurans(FC75), bp 102 degrees C, while a poor solvent for the lung's lining and a good solvent for oxygen and carbon dioxide, proved to cause a characteristic gas/vapor microbubble embolism following intravenous administration as an emulsion. Higher boiling fluorocarbons, e.g. F-tributylamine (FC47), bp 174 degrees C, do not produce such gas-vapor emboli. However, intermediate boiling compounds such as F-decalin (PP5), bp 141 degrees C, produce lungs which, although they certainly appear not to contain microbubble emboli, do not collapse when the thorax is opened. Such hyperinflated non-collapsible lungs (HNCL) occur in the rabbit after the intravenous infusion of F-decalin emulsions as well as after the intratracheal infusion of F-decalin neat liquid. F-decalin induced HNCL retain their appearance and low specific gravity for many weeks, gradually returning toward normal after many months. F-methyl decalin, bp 165 degrees C, does not cause HNCL after intravascular or intratracheal administration. Fluorocarbons having boiling points between 140 degrees C and 165 degrees C are being tested in order to find a perfluorinate with the highest transpiration rate, and hence vapor pressure, compatible with an acceptable body dwell time. We have given fluorocarbons intratracheally to 75, intravenously to 221 and both intratracheally and intravenously to 8 rabbits. Free radical trapping agents, antineutrophil, antiinflammatory and other drugs have been administered without appreciable decrease of HNCL. Fluorocarbon critical solution temperature, lipid solubility, emulsifiability, and other physicochemical properties may mediate the pulmonary effect. One method of preventing and treating low dose F-decalin-induced HNCL in rabbits is described.

Arterial blood gases and brain oxygen availability following infusion of intratracheal fluorocarbon neat liquids

Eight adult New Zealand Swiss rabbits (3-5 kg) having previously implanted chronic bilateral platinum electrodes in the visual cerebral cortex and subcutaneous silver reference electrodes were tranquilized and monitored in multiple 2-3 hour sessions using voltammetric techniques. Six of these were given intratracheal neat liquid fluorocarbons ranging in boiling point from 132 degrees C to 215 degrees C at doses of 2 or 4cc/kg. Each animal received only one fluorocarbon liquid. Two additional rabbits were match-studied as controls. Half of the rabbits have survived more than five months. Both controls and two experimental rabbits were sacrificed after more than seven months due to gastric hairballs. The period of daytime monitoring sessions, when cathodic brain oxygen currents (aO2), arterial blood gases and pH were obtained, was between 34 and 263 days. In some animals the arterial pCO2 was increased during the first week but the pO2 and pH remained nearly normal in all eight animals throughout. The two best fluorocarbons for liquid breathing on the basis of this limited but intensive work are F-methyldecalin and F-5,6H-dec-5-ene (F44E).

A nationwide evaluation of the academic performance of male and female optometry students

The number of women entering optometry has risen steadily over the last two decades. The present study is a nationwide evaluation of the academic performance of male and female optometry students graduating in 1986. The data presented was obtained through the cooperation of 12 of the 15 U.S. schools and colleges of optometry. Factors which were investigated include preoptometry grade point average (GPA), GPA at the end of the first two years of optometry school, GPA for the second two years of optometry (calculated independently from the first two years GPA), Optometry College Admission Test (OCAT) scores, class rank at graduation and awards received at graduation. This analysis revealed very little difference in overall academic performance between male and female optometry students.

An implanted peritoneal oxygen tonometer that can be calibrated in situ

Oxygen tension in the peritoneum has been continuously measured with a Silastic tonometer having an integral oxygen electrode and inlet and outlet tubes for gasequilibrated electrolyte solution. Remote kinetic calibration of the system is periodically performed. Tonometers were implanted in six rabbits. Peritoneal oxygen tension was measured in awake and anesthetized rabbits under various oxygen breathing conditions.

Developmental outcome following posthemorrhagic hydrocephalus in preterm infants. Comparison of twins discordant for hydrocephalus

The mental development and neurologic outcome of four sets of preterm twins, in whom one infant within each pair developed posthemorrhagic hydrocephalus during the neonatal period, were assessed. Each hydrocephalic infant presented with signs of increased intracranial pressure and required placement of a ventriculoperitoneal shunt. Three of the four hydrocephalic infants required revision or replacement of the shunt during the first year. The four nonhydrocephalic infants had normal neurologic outcomes. All four hydrocephalic infants had some neurologic abnormalities on follow-up examination. Neurologic abnormalities were transient in one infant and persistent in three others, each of whom showed evidence of mild right hemiparesis. Within each twin pair, developmental rates and mental test scores were strikingly similar throughout infancy and early childhood. Two of the twin pairs have undergone psychological assessments at 8 and 11 years of age. Relatively lower IQ scores were obtained for the hydrocephalic child in each twin pair at these ages.

Relationship of growth hormone, prolactin and thyrotropin secretion to individual and progeny performance of Hereford bulls

Six Hereford bulls from a line selected with an index of body weight and muscling score were compared with six bulls from a control line to determine if increased growth in the selected line was associated with changes in plasma levels of growth hormone (GH), prolactin (PRL) and (or) thyrotropin (TSH). The predictive value of sire hormone data for growth rate of progeny was also evaluated. Bulls of the index line were heavier at birth (P less than .02) and had higher postweaning daily gains (P less than .01) than bulls of the control line. Blood samples were collected from bulls (ages 2 and 3 yr) at 15-min intervals for 8 h. Overall plasma GH concentrations were higher (P less than .03) in the index bulls than those in the control line. All characteristics of PRL secretion examined tended to be higher in the index bulls, but only mean overall and baseline differences approached significance (P less than .10). There were no significant differences in measures of TSH secretion between lines. Sire differences in hormone characteristics accounted for significant amounts of variation in birth weight and postweaning gain of progeny, but not in gain to weaning. Also, when considered jointly, hormone characteristics generally added significantly to predictions that used sire growth rate alone. The results suggest that serum hormone characteristics in parents may provide additional predictors of growth rates of progeny.

Satellite cell proliferation in response to pituitary hormones

Proliferation of rat skeletal muscle satellite cells was studied in vitro, and their ability to respond to a variety of protein hormones was examined, including: growth hormone, prolactin, luteinizing hormone, thyrotropin and fibroblast growth factor. All experiments were conducted in serum-free medium to avoid complicating interactions with serum constituents such as other hormones or binding proteins. Dose-response curves were constructed for each protein and encompassed the physiological range plus concentrations two to three orders of magnitude greater than the physiological range. Of the proteins examined, the only one shown to have the ability to directly stimulate satellite cell proliferation was fibroblast growth factor. None of the anterior pituitary protein hormones had the ability to interact directly with satellite cells to stimulate proliferation in vitro. Therefore, satellite cells seem to be selective in their response to protein hormones, and the classes identified thus far are hormones in the insulin-like growth factor family and fibroblast growth factor. These two classes of protein hormones are quite different and would not be expected to act through a common pathway. Consequently, we have proposed a dual regulatory system that may allow for local as well as systemic stimulation of satellite cells.

Changes in the auditory brainstem response associated with intravenous infusion of unconjugated bilirubin into infant rhesus monkeys

The auditory brainstem response (ABR) was monitored in nine infant rhesus monkeys during the intravenous infusion of 50-168 mg/kg of unconjugated bilirubin. Sulfisoxazole (200 mg/kg) was sometimes given near the end of or just before the bilirubin infusion if no obvious ABR change had yet occurred. Five of the animals were term gestation, four were preterm, and they ranged from 1 to 40 days of age at the time of study. The three oldest term animals, studied at 20, 35 and 40 days of age, respectively, showed variable changes in the ABR waves during bilirubin infusion and these changes were not altered further by sulfisoxazole administration. The other two term infants, studied at 1 and 6 days of age, respectively, showed sulfisoxazole enhanced ABR wave latency increase and amplitude reduction followed by loss of the ABR. Both of these animals became apneic following ABR loss and eventually died. The ABR reappeared in one animal prior to death. Minimal gross and microscopic changes were present in the brain of the 6-day-old animal at autopsy. The four preterm animals all had a progressive wave amplitude decrease followed by loss of the ABR with bilirubin alone. These preterm animals were sacrificed shortly after the ABR loss with only one showing yellow staining of the basal ganglia at autopsy. The infant rhesus monkey may be a useful paradigm for bilirubin-induced ototoxicity as manifested by potentially reversible ABR changes. The changes are dependent on gestational and chronological age of the animal and appear to occur in the peripheral eighth nerve or cochlea as well as in brainstem pathways.

Ontogeny of growth hormone, prolactin, luteinizing hormone, and testosterone secretory patterns in the ram

The ontogenetic changes that occur in secretory patterns of growth hormone (GH), prolactin (Prl), luteinizing hormone (LH), and testosterone (T) in rams maintained in constant photoperiod were examined. Nine ram lambs were moved to individual pens in a controlled environment (12L: 12D cycle; 18-24 degrees C temperature) at 66 days of age. Blood samples were collected via indwelling cannulae at 15-min intervals for an 8-h period at 80, 136, 192, 248, and 304 days of age. Plasma concentrations of GH, Prl, LH, and T were quantitated and parameters of the secretory patterns determined. Mean concentration of GH tended to decline with age, probably because the amplitude of secretory peaks was significantly reduced with age. There were no age-associated changes in basal concentration of GH or incidence of GH peaks. There was an increase in Prl secretion (as estimated by mean concentration) at 136 and after 248 days of age. Significant age-associated changes occurred in all parameters of LH and T secretion. At the younger ages, testosterone concentrations were low and LH concentrations were elevated. At the older ages the relationship was reversed, with LH low and testosterone high. There were no significant correlations between frequency and magnitude of LH and T peaks. The significant correlations present among parameters of LH and T secretion were between basal concentration of LH and overall mean concentration and basal concentration of T. These results suggest that LH may not be the sole tropic stimulator of acute T secretion.

Increased serum prolactin levels mediate the suppressive effects of ectopic pituitary grafts on copulatory behavior in male rats

To determine if deficits in sexual activity observed in pituitary-grafted male rats are due to elevated serum prolactin (PRL) levels found in these animals, the effects of whole pituitary grafts, pars distalis grafts, and ovine (o) PRL treatment on male copulatory behavior were compared. Adult sexually experienced CDF male rats were given four whole pituitary grafts, four pars distalis grafts, or were sham operated. Both groups of grafted animals exhibited suppressed copulatory behavior patterns when tested 18 days after pituitary transplantation. Animals given whole pituitary grafts had significantly longer latencies to mount (P less than 0.05) and to intromit (P less than 0.01) than did the sham-operated controls, while the animals given anterior pituitary grafts differed from the sham-operated controls in latencies to mount (P less than 0.05) and to intromit (P less than 0.01), as well as in the number of intromissions (P less than 0.05). Prolactin-injected animals had significantly reduced intromission rates (P less than 0.01) and significantly increased latencies to mount (P less than 0.05) and to intromit (P less than 0.01) when compared to vehicle-injected controls. Furthermore, the time course of behavioral suppression was similar in oPRL-treated animals to that observed in pars distalis-grafted males, with both groups showing the onset of deficits in sexual activity within 8 to 9 days from the induction of the hyperprolactinemic state. The similarity in pattern and time to onset of behavioral suppression in pituitary-grafted and oPRL-treated animals suggests that behavioral deficits observed in animals with pituitary grafts result from chronic elevation of serum PRL levels.

Partial purification and characterization of somatomedin from sheep serum

A rapid, high yield preparative technique for the isolation of sheep somatomedin is reported. Purification of biologically active somatomedin from the 60% ammonium sulfate precipitate of sheep serum was accomplished using three gentle fractionation steps. Biological activity during purification was monitored using the rat adipocyte nonsuppressible insulin-like activity (NSILA) assay. A stepwise pH elution (pH 2.85, 3.5, 4.5, and 6.0) from SP-Sephadex resulted in the elimination of more than 99% of the serum proteins and a 500-fold enhancement of biological activity. The active fraction eluted at pH 6.0 and was further fractionated on Sephadex G-50 (fine) chromatography at pH 2.85. This resulted in about a 10,000-fold enhancement of activity over serum activity. The most active fractions from Sephadex chromatography were further separated on reverse phase HPLC in 0.1% trifluoroacetic acid using a linear gradient of 24-60% acetonitrile. The biological activity of the final preparation was enhanced 61,000- to 182,000-fold over that of serum (mean, 93,000-fold) when assayed in the NSILA assay. Protein yield was estimated to be 467 micrograms/liter serum. In addition to the NSILA activity, the final preparation demonstrated dose-dependent sulfation factor activity in the embryonic chick pelvic leaflet bioassay. Sheep somatomedin was active at physiological levels in both bioassays. Analysis of the somatomedin preparation by sodium dodecyl sulfate-electrophoresis at pH 8.8 showed that it was homogeneous by this criterion. The activity eluted from Sephadex G-50 was estimated to have a molecular size of 6900. Two Coomassie blue-stained bands were present in the final sheep somatomedin preparation after polyacrylamide gel electrophoresis at pH 3.2. Our purification process is a rapid, high yield technique which yields a polypeptide fraction enriched in NSILA and somatomedin-like activity. The molecular size and biological activity in the NSILA and sulfation factor assays suggest that our sheep NSILA is analogous to somatomedins purified from other species of animals.

Clinical correlations of serial somatosensory evoked potentials in multiple sclerosis

Serial median nerve somatosensory evoked potentials (SEPs) were recorded in 12 patients with definite MS. On the initial tests, there was no clear association between the severity of clinical disease activity and SEP findings. The cervical response was most frequently affected and, when present, was often abnormal in configuration, suggesting absence or delay in the far field P14 component with preservation of cervical N11 and N13 components. Clinical motor and sensory findings in the corresponding limb frequently correlated with abnormalities of the cervical response. When new motor and sensory findings developed in the arms during the study, the SEP deteriorated in some patients but improved in others. Most SEP changes were not accompanied by clinical changes. Overall disability sometimes increased during the study despite improvements in the SEP.