Insufficient Impact: Limited Implementation of Federal Regulatory Changes to Methadone and Buprenorphine Access in Arizona During COVID-19

Introduction

This study examined the impact of federal regulatory changes on methadone and buprenorphine treatment during COVID-19 in Arizona.

Methods

A cohort study of methadone and buprenorphine providers from September 14, 2021 to April 15, 2022 measured the proportion of 6 treatment accommodations implemented at 3 time periods: before COVID-19, during Arizona's COVID-19 shutdown, and at the time of the survey completion. Accommodations included (1) telehealth, (2) telehealth buprenorphine induction, (3) increased multiday dosing, (4) license reciprocity, (5) home medications delivery, and (6) off-site dispensing. A multilevel model assessed the association of treatment setting, rurality, and treatment with accommodation implementation time.

Results

Over half (62.2%) of the 74-provider sample practiced in healthcare settings not primarily focused on addiction treatment, 19% practiced in methadone clinics, and 19% practiced in treatment clinics not offering methadone. Almost half (43%) were unaware of the regulatory changes allowing treatment accommodation. Telehealth was most frequently reported, increasing from 30% before COVID-19 to 80% at the time of the survey. Multiday dosing was the only accommodation substantially retracted after COVID-19 shutdown: from 41% to 23% at the time of the survey. Providers with higher patient limits were 2.5-3.2 times as likely to implement telehealth services, 4.4 times as likely to implement buprenorphine induction through telehealth, and 15.2-20.9 times as likely to implement license reciprocity as providers with lower patient limits. Providers of methadone implemented 12% more accommodations and maintained a higher average proportion of implemented accommodations during the COVID-19 shutdown period but were more likely to reduce the proportion of implemented accommodations (a 17-percentage point gap by the time of the survey).

Conclusions

Federal regulatory changes are not sufficient to produce a substantive or sustained impact on provider accommodations, especially in methadone medical treatment settings. Practice change interventions specific to treatment settings should be implemented and studied for their impact.

They "Don't Know How to Deal with People Like Me": Assessing Health Care Experiences of Gender Minorities in Indiana

Purpose

Within the LGBTQ+ community, the transgender and nonbinary (TGNB) population experience a disproportionate amount of discrimination when seeking health care. Such disparities may arise from lack of proper medical training and resources for providers or biases. In this study, we examine the health care experiences of TGNB individuals living in Southern Indiana.

Methods

We analyzed responses from TGNB respondents to an LGBTQ+ health care needs assessment survey in Southern Indiana. Respondents were asked about demographic data, their self-assessed health status, quality of health care received, whether they have a provider with whom they feel comfortable sharing their gender identity with, and if they have to commute to see their provider. Finally, respondents were asked an open-ended question about their health care experiences while living in Southern Indiana. Responses were coded and several themes emerged and were analyzed.

Results

Eighty-five TGNB individuals completed our survey. Less than half of respondents indicated that they had an LGBTQ+-welcoming provider (44.7%). Individuals with an LGBTQ+-welcoming provider were more likely to report their self-assessed health as excellent/good (p=0.02) and quality of health as excellent/very good (p=0.03) compared to individuals without an LGBTQ+-welcoming provider. Five themes emerged from the write-in responses (n=64): discrimination (34.4%), invalidation (32.8%), distrust (28.1%), logistic concerns (35.9%), and positive experiences (35.9%).

Conclusion

The TGNB community living in Southern Indiana reports numerous barriers related to provider attitudes when obtaining health care. Additional training is needed to address provider biases and improve LGBTQ+ community health disparities.

Assessing Whether Medical Students Consistently Ask Patients About Sexual Orientation and Gender Identity as a Function of Year in Training

Purpose: The Institute of Medicine has suggested that teaching health care providers to inquire about and document the sexual orientation and gender identity (SOGI) of their patients will provide more accurate epidemiological data and allow for more patient-centered care, thus improving sexual and gender minority health. The purpose of this study was to determine whether medical students are asking about SOGI and to identify reasons why students were opting not to ask. Methods: In July 2020, an online survey was made available to second-, third-, and fourth-year medical students at a Midwestern medical school. Respondents were asked whether they consistently inquired about the SOGI of their patients, and the reasons they do not ask. The number of students asking about SOGI and reasons for not asking were analyzed using chi-square analyses as a function of year in training. Results: Of 1089 eligible participants, 364 completed the survey (33.4%). The number of students asking about sexual orientation significantly decreased with every year of training (92.8%, 82.2%, and 52.7%). The number of students asking about gender identity significantly decreased after the second year of training (69.9%, 40.6%, and 26.4%). Reasons that significantly increased across training included believing SOGI is irrelevant to encounters, limiting inquiries to patients with sexual health complaints only, and negative influence from their attendings. Conclusion: As medical students progressed into the clinical years of their training, they were less likely to ask their patients about SOGI and more likely to cite negative influence from their attendings and question the relevance of obtaining SOGI.

Predicting Pharmacist Dispensing Practices and Comfort Related to Pre-exposure Prophylaxis for HIV Prevention (PrEP)

To identify factors associated with pharmacist dispensing practice and comfort counseling patients about pre-exposure prophylaxis for HIV prevention (PrEP). Cross-sectional 2016 census of Indiana managing pharmacists measured PrEP awareness, comfort dispensing and counseling patients. Modified Poisson models with robust error variance estimated relative risks and confidence intervals. 15.8% of 284 pharmacists had dispensed PrEP and 11.6% had consulted about it. Dispensing and comfort counseling were associated with confidence in knowledge about PrEP medication adherence and adverse effects of PrEP medication; awareness about PrEP before the survey, number of full time pharmacists in their pharmacy, and increases in new HIV cases from 2015 to 2016 in communities served. Comfort counseling about PrEP was associated with the belief that pharmacists can be an important resource for HIV and HCV treatment.

Optical properties of intact leaves for estimating chlorophyll concentration

Changes in leaf chlorophyll content can serve as relative indicators of plant vigor and environmental quality. This study identified reflectance, transmittance, and absorptance wavebands and band ratios within the 400- to 850-nm range for intact leaves that could be used to estimate extracted leaf chlorophyll per unit leaf area (areal concentration) with minimal error. Leaf optical properties along with chlorophyll a, b, and a + b concentrations were measured for the planar-leaved sweetgum (Liquidambar styraciflua L.), red maple (Acer rubrum L.), wild grape (Vitis rotundifolia Michx.), and switchcane [Arundinaria gigantea (Walter) Muhl.], and for needles of longleaf pine (Pinus palustris Miller). Generally, reflectance, transmittance, and absorptance corresponded most precisely with chlorophyll concentrations at wavelengths near 700 nm, although regressions were also strong in the 550- to 625-nm range. A power function was superior to a simple linear function in yielding low standard deviations of the estimate (s). When data were combined among the planar-leaved species, s values were low at approximately 50 mumol/m2 out of a 940 mumol/m2 range in chlorophyll a + b at best-fit wavelengths of 707 to 709 nm. Minimal s values for chlorophyll a + b ranged from 32 to 62 mumol/m2 across species when band ratios having numerator wavelengths of 693 to 720 nm were used with the application of a power function. Optimal denominator wavelengths for the band ratios were 850 nm for reflectance and transmittance and 400 nm for absorptance. This information can be applied in designing field portable chlorophyll meters and in the landscape-scale remote sensing of plant responses to the environment.

Leaf optical properties in higher plants: linking spectral characteristics to stress and chlorophyll concentration

A number of studies have linked responses in leaf spectral reflectance, transmittance, or absorptance to physiological stress. A variety of stressors including dehydration, flooding, freezing, ozone, herbicides, competition, disease, insects, and deficiencies in ectomycorrhizal development and N fertilization have been imposed on species ranging from grasses to conifers and deciduous trees. In all cases, the maximum difference in reflectance within the 400-850 nm wavelength range between control and stressed states occurred as a reflectance increase at wavelengths near 700 nm. In studies that included transmittance and absorptance as well as reflectance, maximum differences occurred as increases and decreases, respectively, near 700 nm. This common optical response to stress could be simulated closely by varying the chlorophyll concentration of model leaves (fiberglass filter pads) and by the natural variability in leaf chlorophyll concentrations in senescent leaves of five species. The optical response to stress near 700 nm, as well as corresponding changes in reflectance that occur in the green-yellow spectrum, can be explained by the general tendency of stress to reduce leaf chlorophyll concentration.

Effects of elevated atmospheric CO(2) and temperature on leaf optical properties in Acer saccharum

Elevated partial pressures of atmospheric carbon dioxide, similar to numerous causes of plant stress, may alter leaf pigmentation and structure and thus would be expected to alter leaf optical properties. Hypotheses that elevated CO(2) pressure and air temperature would alter leaf optical properties were tested for sugar maple (Acer saccharum) in the middle of its fourth growing season under treatment. The saplings had been growing since 1994 in open-top chambers and partial shade at Oak Ridge, Tennessee under the following treatments: (1) ambient CO(2) pressure and air temperature (control); (2) CO(2) pressure approximately 30 Pa above ambient; (3) air temperatures 3 degrees C above ambient; and (4) elevated CO(2) and air temperature. Under elevated CO(2) or temperature, spectral reflectance, transmittance and absorptance in the visible spectrum (400-720 nm) tended to change in patterns that generally are associated with chlorosis, with maximum differences from the control near 700 nm. However, these changes were not significant at P=0.05. Although reflectance, transmittance and absorptance at 700 nm correlated strongly with leaf chlorophyll concentration, variability in chlorophyll concentration was greater within than among treatments. The lack of treatment effects on pigmentation explained the non-significant change in optical properties in the visible spectrum. Optical properties in the near-infrared (721-850 nm) were similarly unresponsive to treatment with the exception of an increased absorptance throughout the 739-850 nm range in leaves that developed under elevated air temperature alone. This response might have resulted from effects of air temperature on leaf internal structure.

Flowers produce variations in color saturation by arranging petals at oblique and varying angles

Large color variations can be observed across the face of a flower even when individual petals are the same color. We investigated whether these color variations could be explained by a model that incorporates multiple reflections of light between petals and transmissions of light through petals before the light returns to the observer. The three flowers that we selected for the study exhibited large color variations across the face of the intact flower but had no significant observable difference in color saturation across a single petal or between petals when petals were removed from the flower. We used a spectroradiometer to measure the spectrum across the faces of intact flowers and across individual petals. The measured spectra for all of the flowers were consistent with the proposed model.

Obtaining the four-chamber view to diagnose fetal cardiac anomalies

Four-chamber view screening of the fetal heart was greeted with significant optimism in the mid-1980s. This screening technique was initially expected to detect most congenital heart disease in utero; however, recent studies demonstrate a 4% to 40% sensitivity of four-chamber view screening. It is therefore probable that the dream of antepartum diagnosis of most congenital heart disease in utero will remain unfulfilled. This is particularly true with increasing funding constraints for health care provision imposed by both the federal government and third-party payors.

Longitudinal dental arch changes in adults

This study examined changes in the dental arches that occur in untreated persons between late adolescence and the fifth or sixth decade of life. Longitudinal dental casts from 82 subjects were obtained as part of a recall study of subjects from the University of Michigan Elementary and Secondary School Growth Study. From the parent sample, three groups were identified. The untreated sample comprised 53 subjects (27 males and 26 females). A midadult sample of 10 persons, who had an additional set of records taken on average during their fourth decade of life also was analyzed, as was a sample of 13 subjects who received orthodontic treatment as adolescents and were about 30 years posttreatment. Measures of dental arch width, arch depth, and arch perimeter were evaluated with the aid of digital-imaging hardware and software. Incisor irregularity, curve of Spee, overjet, and overbite were measured directly from the dental casts. Statistically significant decrements occurred in arch width, depth, and perimeter. The mean decrement in any one dimension was less than 3 mm. At all times, males displayed significantly more mandibular incisor irregularity than females. In addition, the increase in mandibular incisor irregularity that occurred in male and female subjects was the same. However, irregularity did not increase in all subjects; it decreased in 3% of the males and 7% of the females. In general, overbite, overjet, and curve of Spee were stable during adulthood. Statistically significant correlations between the changes in dental arch measures could not be established.

The microcomputer as a clinical research tool

A microcomputer system has been developed for clinical perinatal-neonatal research. This system is composed of commercially available hardware and software that is readily available, relatively inexpensive, and easy to learn to use. Systems like this permit compilation of data, statistical analysis, and the possibility of intercommunication with other microcomputers and mainframe systems in collaborative research endeavors. Further, microcomputer systems allow investigators immediate access to data and data analysis within their own offices.

Autosomal dominant supravalvular aortic stenosis: large three-generation family

Supravalvular aortic stenosis (SVAS) can be inherited as an isolated autosomal dominant trait or can be a component manifestation of the Williams syndrome. Some consider the Williams syndrome to be due to more severe expression of the gene defect that causes isolated SVAS. We describe a family with isolated SVAS that is the largest thoroughly studied family with this disorder to our knowledge; no patients in this family had Williams syndrome. Five members of this family were reported by Lewis et al. (Dis Chest 55:372-379, 1969). We reevaluated this family and now include examinations of the parents, additional sibs and children of the original 5 patients. Twenty relatives had physical and echocardiographic examinations. In addition, information from outside sources was obtained on 7 relatives not personally evaluated. The SVAS showed marked variability of expression and was not associated with mental retardation or with the facial manifestations of Williams syndrome. We think that previous reports of Williams syndrome reputedly occurring within the same family as isolated autosomal dominant SVAS were inadequately documented. Based on our family and review of the literature, we suggest that isolated SVAS and Williams syndrome represent clinically distinct entities.

Photosynthesis in an open field for exotic versus native vines of the southeastern United States

The potential importance of leaf gas exchange to the prolific growth characteristics of the exotic vines Pueraria lobata and Lonicera japonica versus the native vines Rhus radicans, Parthenocissus quinquefolia, Vitis vulpina, and Clematis virginiana was evaluated. Under high irradiance and low leaf-air water vapor pressure difference, photosynthesis was similar (23 – 27 μmol∙m−2∙s−1) among species with the exception of R. radicans (16 μmol∙m−2∙s−1). Conductance and transpiration were greater in Pueraria lobata than in the other species. When the leaf-air vapor pressure difference was high (4.0 kPa) photosynthesis in the exotic vines decreased more than in several of the native species. Photosynthesis in L. japonica and Parthenocissus quinquefolia, and to a lesser extent in Pueraria lobata, was reduced by high vapor pressure differences even though internal CO2 partial pressures remained relatively high, suggesting a nonstomatal reduction of photosynthetic capacity. Thus, the highly prolific growth typical of the exotic vines may not be attributable to greater steady-state photosynthesis.

Spectrum of findings in a family with nonsyndromic autosomal dominant supravalvular aortic stenosis: a Doppler echocardiographic study

Nonsyndromic familial supravalvular aortic stenosis is an autosomal dominant disorder. However, for many reported families, systematic study of all family members with echocardiographic or hemodynamic techniques has not been performed and degree of penetrance has not been assessed. The supravalvular stenosis in these family members usually is not associated with mental retardation or other characteristics of Williams syndrome. Although some believe that autosomal dominant supravalvular aortic stenosis is part of the spectrum of Williams syndrome, others believe that these are separate entities. Doppler echocardiograms were analyzed on 23 members of a 34 member family with several known to have supravalvular aortic stenosis; 20 studies were performed by the authors and 3 were done elsewhere and made available for review. No family member had mental retardation, characteristic facies or other findings of Williams syndrome. Three of the 34 had supravalvular aortic stenosis requiring surgery. Of 22 members examined echocardiographically who had not had prior surgical repair, 13 had supravalvular aortic stenosis. Echocardiographic findings ranged widely, from calcification of the ascending aorta in a 71 year old man with minimally increased flow velocity (1.7 m/s) to mild narrowing with mildly increased flow velocity in six members to significant narrowing with impressively increased flow velocity (2 to 4 m/s) in seven. In addition, four patients had mild narrowing of pulmonary artery branches and eight had peak pulmonary artery flow velocity above normal. This study demonstrates complete penetrance with extremely variable expression in this family with autosomal dominant supravalvular aortic stenosis and emphasizes the importance of using echocardiographic techniques in studying the family members who are suspected of having an inherited cardiovascular disease.

Nonsummer stomatal conductance for the invasive vines kudzu and Japanese honeysuckle

A field study was conducted in Maryland to estimate nonsummer stomatal conductances on clear days for two invasive woody vine species common to the southeastern United States. Before the first frost in late October, stomatal conductances were similar for kudzu (Pueraria lobata) and Japanese honeysuckle (Lonicera japonica). When minimum predawn air temperature fell to −0.6 °C, kudzu leaves were irreversibly damaged, whereas maximum daily conductance in honeysuckle was unaffected. Maximum conductances in honeysuckle increased to 14 mm s−1 in late November and mid-December, similar to late-spring and summer values. When minimum air temperatures decreased to −2.8 °C in January, conductance still remained above 5 mm s−1. Maximum daily conductance was lowest in early March, corresponding with low leaf temperatures. By mid-April, maximum conductance increased to 10 mm s−1. Conductances suggested that rates of leaf gas exchange in honeysuckle during fall, winter, and spring were relatively high. Carbon gain during this period might thus contribute substantially to the invasive growth characteristic of the species.

Microhabitat comparisons of transpiration and photosynthesis in three subalpine conifers

Differences in water and photosynthetic relations were compared for three codominant conifers (Engelmann spruce (Picea engelmaniï), subalpine fir (Abies lasiocarpa), and lodgepole pine (Pinus contorta) at microhabitats within a subalpine forest (central Rocky Mountains, U.S.A.) that were considered representative of different successional stages. Diumal measurements of photosynthesis, leaf conductance, and transpiration were taken at microhabitats considered early-successional (open), intermediate (forest gap), and late-successional (forest understory) environments to evaluate possible influences of gas-exchange physiology in observed distributional and successional patterns. Pine had greater water-use efficiency (photosynthesis/transpiration) in early- versus late-successional environments, primarily as a result of a lower leaf conductance and transpiration. Photosynthetic performance was similar among all three species at each respective microhabitat and increased as the openness of the microhabitat increased. Greater water-use efficiency may significantly improve the growth of pine over spruce and fir on more open, drier sites at lower elevation. Higher transpiration in spruce and fir may limit these species to higher elevation sites, to understory sites at middle elevations, and to moister open sites at lower elevations (e.g., riparian sites).

Deletion of the distal long arm of chromosome 1: a definable syndrome

Based on analysis of 15 cases, there appears to be a characteristic facial appearance and pattern of associated malformations that would allow clinical delineation of deletion of the distal bands of 1q. Characteristic manifestations include round face with prominent "cupid's bow" and downturned corners of the mouth, thin vermilion borders of lips, long upper lip with smooth philtrum, short and broad nose, epicanthal folds, apparently low-set ears, micrognathia, microcephaly, abnormal hands and feet, variable cardiac, genital, and other anomalies, moderate to severe mental retardation, and growth retardation. The deletion includes 1q42 or 1q43----qter and was a de novo defect in nine of 15 cases.

Influence of shoot structure on light interception and photosynthesis in conifers

The influence of shoot structure on net photosynthesis was evaluated under field conditions for the central Rocky Mountain (United States) conifers Picea engelmannii (Parry ex Engelm.), Abies lasiocarpa ([Hook] Nutt.), and Pinus contorta (Engelm.). In all species, the greater number of needles per unit stem length on sun shoots correlated with a smaller silhouette leaf area to total leaf area ratio (STAR). Decreased STAR was due primarily to greater needle inclination toward the vertical, plus some needle mutual shading. However, photosynthesis expressed on a total leaf area basis did not decrease in sun shoots (lower STAR) but remained nearly constant at approximately 3 micromoles per square meter per second over a wide range of STAR (0.1 to 0.3). Relatively low light saturation levels of 200 to 1400 microeinsteins per square meter per second and diffuse light to 350 microeinsteins per meter per second maintained photosynthetic flux densities in inclined and/or shaded needles at levels comparable to those in unshaded needles oriented perpendicular to the solar beam. As a result, net CO(2) uptake per unit stem length increased as much as 2-fold in sun shoots (low STAR) in direct proportion to increasing needle density.

Aortitis and large vessel arteritis in a newborn

Disseminated arteritis with extensive involvement of the aorta, as well as involvement of the arch vessels, coronary arteries, and pulmonary arteries, but not of the arteries within the liver, spleen, kidneys, or other organs, is unusual in a newborn. The presence of both acute and chronic inflammation with fibrosis, as well as calcification and focal ossification in the aorta, would suggest that the process had been present for some time before birth. This lesion should be described rather than designated by an eponym or included with such entities as Takayasu's disease. An additional finding of interest was widespread calcification in Bowman's capsules of numerous glomeruli.

Persistent left superior vena cava and associated structural and functional considerations

Potentially significant associations are presented between anomalous systemic venous return (including both left superior vena cava and left hepatic venous drainage to the coronary sinus), a history of atrial fibrillation and a forme fruste of cor triatriatum in an elderly woman. Lack of associated structural defects or functional deficits makes it difficult to assess the frequency of occurrence in the general population of bilateral superior venae cavae in association with a persistent left hepatic vein draining into the coronary sinus. However, the potential for these systemic venous anomalies needs to be considered when unexplained arrhythmias are encountered. More specifically, the size of the coronary sinus needs to be assessed in patients with arrhythmia.

Triglyceride and cholesterol concentrations in whole serum and in serum lipoproteins in Reye syndrome

Triglyceride and cholesterol concentrations in whole serum and in the serum lipoprotein fractions were measured during the course of hospitalization in six patients with Reye syndrome, four of whom survived. Very low density lipoprotein (VLDL) triglycerides were significantly lower on admission than on the last day of hospitalization. However, no VLDL triglyceride value was below the normal range. Triglyceride transport was increased in low density lipoprotein (LDL) and high density lipoprotein (HDL) fractions. LDL and HDL cholesterol concentrations were low on admission and decreased further during hospitalization. The changes in LDL and HDL cholesterol concentrations were more severe among nonsurvivors. No HDL cholesterol was detected in nonsurvivors on the last day of hospitalization. These results suggest that decreased VLDL triglycerides may not play an important role in the development of fatty liver and that decreased LDL and HDL cholesterol concentrations may be of prognostic value in Reye syndrome.

The cholesterol turnover, synthesis, and absorption in two sisters with familial hypercholesterolemia (type IIa)

To explore the mechanisms of the profound plasma cholesterol elevations in familial homozygous hypercholesterolemia (type IIa), cholesterol turnover, sterol balance, cholesterol absorption, and low density lipoprotein studies were carried out under controlled dietary conditions in two sisters (aged 13 and 16). Cholesterol turnover was prolonged. The half-life of the first exponential of the plasma cholesterol specific activity decay curve was double that of normal adults. The rate constants for the removal of cholesterol from pool A (KAA = 0.0652) and for the excretion of cholesterol from the system (Kaa = 0.0197) were less than half of normal. The production rates of cholesterol were low, only 6.30 and 6.86 mg/kg per day as measured by cholesterol turnover and sterol balance techniques, respectively. Fecal neutral steroid and bile acid excretion were 5.22 and 1.64 mg/kg per day, which is remarkably low in comparison to those of normal and heterozygous children. Cholesterol absorption was within the upper limit of the values reported for normal adults. THE HDL cholesterol values were extremely low (27 mg/dl) in contrast to profoundly elevated LDL levels. The fractional catabolic rate of LDL (0.127 per day) and the rate of synthesis and catabolism of apo-LDL (15 mg/kg per day) were low in comparison to previously reported values in homozygotes. These composite data indicated that the definable metabolic defects of these two sisters with homozygous familial hypercholesterolemia were the sluggish clearance of cholesterol from the body coupled with low total body synthesis of cholesterol.

Synthesis and systemic fungicidal activity of N-(2-Bromo-2,2-dichloro-1-arylaminoethyl)formamides and related compounds

The synthesis of several analogues of the fungicides triforine and chloraniformethan is described. The compounds comprise N-(2,2,2- trichloro-1-arylaminoethyl)formamides and N-(2-bromo-2,2-dichloro-1- arylaminoethyl)formamides. Several of the compounds are highly effective protectant and systemic fungicides.

Retrograde catheterization of the pulmonary veins following surgical correction of transposition of the great vessels

Prior to a Mustard repair for transposition of the great vessels, complete physiologic data of the pulmonary bed can be obtained by catheterization of the pulmonary artery with a "J" formed wire, and direct catheterization of the pulmonary veins via an atrial septal defect. Following "physiologic" repair ready access to the pulmonary veins is denied. Evaluation of the pulmonary venous pressure is of great importance, however, in differentiating pulmonary vascular disease from pulmonary hypertension secondary to patch obstruction of pulmonary venous return. This paper describes a technique of catheterization of the pulmonary veins following a Mustard repair for TGV.

Percutaneous carciac catheterization of the neonate

A modified Seldinger percutaneous approach for catheterization was used for cardiac evaluation and monitoring of infants weighing less than 4,520 gm. From January 1968, through April 1971, 160 left- and 230 right-sided cardiac procedures were done. After July 1969 81% of all left-and 42% of all right-sided procedures were done percutaneously. After October 1969 catheters were also inserted percutaneously in 20 infants for intensive care monitoring. During this period three children were noted to have dimished pulse on discharge, two were noted to have vascular thrombosis, and two had episodes of bleeding from the catheter site requiring transfusion of fresh blood. Both instances of vascular thrombosis occurred in infants with monitoring catheters. The percutaneous method of catheter insertion into the femoral vessels offers a safe method for cardiac catheterization of the neonate and of insertion of monitoring catheters where the umbilical route is not feasible. Vessel continuity is also preserved, providing a route for repeated studies if necessary.