760 IMPROVING THE MANAGEMENT AND DURATION OF RESOLUTION OF ACUTE KIDNEY INJURY IN THE ELDERLY

Introduction

Acute Kidney Injury (AKI) is prevalent in elderly populations due to several factors: polypharmacy, anatomic/physiologic changes of the kidneys associated with aging. AKI can contribute to increased length of stay, morbidity and mortality. This audit sets out to establish if the guidance established by NICE is being followed and how it may be better implemented.

Method

This study audited patients ≥65 years, who were admitted with AKI/developed an AKI during admission. Patients were excluded if they were on renal replacement therapy or under palliative care. Data was collected from case notes and Clinical Work Station. Data collection points used included: senior review within 24 hours; assessment of fluid status; medication review; strict fluid balance; examine for retention +/− catheter; daily U&E and appropriate imaging. Our independent variable was an AKI sticker, this included a revised checklist for above data collection points that was applied to patients’ medical notes. In addition to this, we used posters on appropriate wards which explained the guidance and management of AKI. Awareness was continued by presenting at Care of The Elderly teaching and medical grand round. Then re-audited the following month.

Results

Both cycles involved 45 patients. After implementation, improvements in urine analysis (5%vs35%), assessments of retention (0%vs38%) and assessments of fluid balance (55%vs78%) were seen. In cycle 2, medication was reviewed more frequently, specifically a 30% increase in the review of nephrotoxics. While senior review within 24 hours remains high in both cycles. We measured the outcome by checking the resolution time of AKI. Mean Resolution time was reduced by 1.4 days.

Conclusion

This audit has demonstrated an increase in the optimisation of the management of AKI through ensuring all appropriate interventions and examinations are completed and reducing resolution time by using stickers and the posters.

Vestibular Implant Imaging

Analogous to hearing restoration via cochlear implants, vestibular function could be restored via vestibular implants that electrically stimulate vestibular nerve branches to encode head motion. This study presents the technical feasibility and first imaging results of CT for vestibular implants in 8 participants of the first-in-human Multichannel Vestibular Implant Early Feasibility Study. Imaging characteristics of 8 participants (3 men, 5 women; median age, 59.5 years; range, 51-66 years) implanted with a Multichannel Vestibular Implant System who underwent a postimplantation multislice CT (n = 2) or flat panel CT (n = 6) are reported. The device comprises 9 platinum electrodes inserted into the ampullae of the 3 semicircular canals and 1 reference electrode inserted in the common crus. Electrode insertion site, positions, length and angle of insertion, and number of artifacts were assessed. Individual electrode contacts were barely discernible in the 2 participants imaged using multislice CT. Electrode and osseous structures were detectable but blurred so that only 12 of the 18 stimulating electrode contacts could be individually identified. Flat panel CT could identify all 10 electrode contacts in all 6 participants. The median reference electrode insertion depth angle was 9° (range, -57.5° to 45°), and the median reference electrode insertion length was 42 mm (range, -21-66 mm). Flat panel CT of vestibular implants produces higher-resolution images with fewer artifacts than multidetector row CT, allowing visualization of individual electrode contacts and quantification of their locations relative to vestibular semicircular canals and ampullae. As multichannel vestibular implant imaging improves, so will our understanding of the relationship between electrode placement and vestibular performance.

Hormonal evidence supports the theory of selection in utero

OBJECTIVES

Antagonists in the debate over whether the maternal stress response during pregnancy damages or culls fetuses have invoked the theory of selection in utero to support opposing positions. We describe how these opposing arguments arise from the same theory and offer a novel test to discriminate between them. Our test, rooted in reports from population endocrinology that human chorionic gonadotropin (hCG) signals fetal fitness, contributes not only to the debate over the fetal origins of illness, but also to the more basic literature concerned with whether and how natural selection in utero affects contemporary human populations.

METHODS

We linked maternal serum hCG measurements from prenatal screening tests with data from the California Department of Public Health birth registry for the years 2001-2007. We used time series analysis to test the association between the number of live-born male singletons and median hCG concentration among males in monthly gestational cohorts.

RESULTS

Among the 1.56 million gestations in our analysis, we find that median hCG levels among male survivors of monthly conception cohorts rise as the number of male survivors falls.

RESULTS

Elevated median hCG among relatively small male birth cohorts supports the theory of selection in utero and suggests that the maternal stress response culls cohorts in gestation by raising the fitness criterion for survival to birth.

Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer

Women's experience of breast cancer is complex, affecting all aspects of life during and after treatment. Patients' perspectives about common impairments and functional limitations secondary to breast cancer treatment, including upper extremity motion restriction, lymphedema, fatigue, weight gain, pain, and chemotherapy-induced peripheral neuropathy, are addressed. Women often report being uninformed regarding these side effects and surprised that they do not always disappear after treatment, but remain part of their lives. Breast cancer patients express strong, unmet needs for education, information, and intervention for these side effects. Evidence suggests that rehabilitation and exercise are effective in preventing and managing many physical side effects of breast cancer treatment. Nevertheless, few women are referred to rehabilitation during or after treatment, and fewer receive baseline assessments of impairment and function to facilitate early detection of impairment and functional limitations. The prospective surveillance model of rehabilitation will serve the needs of women with breast cancer by providing education and information about treatment side effects, reducing the incidence and burden of side effects through early identification and treatment, and enhancing access to timely rehabilitation. Integration of exercise as a component of the model benefits patients at every phase of survivorship, by addressing individual concerns about exercise during and after treatment and highlighting the important contribution of exercise to overall health and survival. The prospective surveillance model of rehabilitation can meet the evident and often expressed needs of survivors for information, guidance, and intervention--thus addressing, and potentially improving, overall quality of life for individuals diagnosed with and treated for breast cancer.

Effects of Tai Chi Exercise on Physical and Mental Health of College Students

The purpose of this pilot study is to examine the effects of Tai Chi Quan, a body-mind harmony exercise, on college students' perceptions of their physical and mental health. A three-month intervention of Tai Chi exercise was administered to college students, and multidimensional physical (PHD) and mental (MHD) health scores were assessed using the SF-36v2 health survey questionnaire before and after the intervention. Thirty college students participated in a 1-hour-long Tai Chi exercise intervention twice a week for 3 months. Each practice session included 10 minutes of breathing and stretching exercises followed by 50 minutes of Tai Chi Quan 24-form practice. PHD including physical function (PF), role physical (RP), bodily pain (BP), general health (GH), and MHD including social function (SF), role mental/emotion function (RE), vitality (VT), perceptions of mental health (MH) were assessed. The normalized scores of each variable and the combined PHD or MHD scores before and after the Tai Chi intervention were examined by paired t-test ( p <0.05). Physical measures of BP and GH, and mental measures of RE, VT and MH were significantly improved after Tai Chi exercise intervention. When the overall PHD or MHD scores were evaluated, the MHD had increased significantly. In conclusion, Tai Chi exercise had positive effects on the self-assessed physical and mental health of college students. Scores on the mental health dimension appeared to be particularly sensitive to change. Colleges/universities might consider offering Tai Chi as a component of their ongoing physical activity programs available to students.

Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment

Intracranial DAVFs are pathologic dural-based shunts and account for 10%-15% of all intracranial arteriovenous malformations. These malformations derive their arterial supply primarily from meningeal vessels, and the venous drainage is either via dural venous sinuses or through the cortical veins. DAVFs have a reported association with dural sinus thrombosis, venous hypertension, previous craniotomy, and trauma, though many lesions are idiopathic. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging. Cross-sectional imaging techniques by using CT and MR imaging aid in the diagnosis, but conventional angiography remains the most accurate method for complete characterization and classification of DAVFs. The pattern of venous drainage observed on dynamic vascular imaging determines the type of DAVF and correlates with the severity of symptoms and the risk of hemorrhage.

Expression of inflammatory cytokines by adipose tissue from patients with endometrial cancer

Obesity results in increased mortality from many forms of cancer. We looked at the levels of gene expression for TNFalpha, IL-6, IkappaB kinase (inhibitor of NF-kappaB), CD 68 (glycoprotein expressed on macrophages) and leptin in samples of adipose tissue from individuals with endometrial cancer versus patients with benign conditions. This is a prospective study which included patients of a gynecologic oncology group. A piece of omental tissue was harvested from them during surgery. RNA was purified from all samples. Relative amounts of RNA for IkappaB, TNFalpha, IL-6, CD68 and leptin were calculated. Pearson's correlation method was used to correlate RNA levels with BMI. Logistic regression method was used to compare gene expression for cancer and control groups. The total sample size was 56 (24 endometrial cancer and 32 controls). IkappaB, TNFalpha and IL-6 levels increased linearly with increasing BMI in the control group. There was no correlation of IkappaB, TNFalpha, IL-6 or CD-68 levels with cancer status of the patients. Leptin had a weak protective effect against endometrial cancer (odds ratio = 0.92). Obesity is associated with increased expression of certain inflammatory cytokines in the adipose tissue. However, increased levels of these inflammatory markers in the adipose tissue of the omentum are not associated with presence of endometrial cancer.

Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting

BACKGROUND

There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT(3) inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms.

OBJECTIVES

The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts.

SELECTION CRITERIA

Randomized trials of acupuncture-point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both.

DATA COLLECTION AND ANALYSIS

Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes.

MAIN RESULTS

Eleven trials (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% confidence interval 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% confidence interval 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% confidence interval -0.37 to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics.

AUTHORS' CONCLUSIONS

This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.

Cystic fibrosis screening in newborns: results from existing programs

Newborn screening for cystic fibrosis (CF) provides early identification and initiation of treatment to infants with this fatal and often misdiagnosed genetic disease. Although reports of health benefits continue to mount from decade-old screening programs in Wisconsin, France, and Australia, newborn screening for CF is still a highly debated topic in genetic policy development. This article summarizes the literature published between May 2000 and April 2001 regarding the health benefits, risks, cost-effectiveness, and programmatic issues of newborn screening for CF. The literature consistently shows evidence of benefits and lack of harm from newborn screening for CF.

The relationship of neighborhood socioeconomic characteristics to birthweight among 5 ethnic groups in California

OBJECTIVES

This study sought to examine relationships between neighborhood socioeconomic characteristics and birthweight, accounting for individual socioeconomic characteristics, among 5 ethnic groups.

METHODS

Birth records were linked to census block-group data for 22 304 women delivering infants at 18 California hospitals during 1994-1995. Information on income and additional factors was obtained from a surveyed subset of 8457 women. Neighborhood levels of poverty, unemployment, and education were examined.

RESULTS

After adjustment for mothers' individual socioeconomic characteristics and other risk factors, less-favorable neighborhood socioeconomic characteristics were associated with lower birthweight among Blacks and Asians. No consistent relationship between neighborhood socioeconomic characteristics and birthweight was found among Whites, US-born Latinas, or foreign-born Latinas overall, but birthweight increased with less-favorable neighborhood socioeconomic characteristics among foreign-born Latinas in high-poverty or high-unemployment neighborhoods. These findings were not explained by measured behavioral or cultural factors.

CONCLUSIONS

In addition to individual socioeconomic characteristics, living in neighborhoods that are less socioeconomically advantaged may differentially influence birthweight, depending on women's ethnicity and nativity.

Access to care for children of the working poor

CONTEXT

Recent evidence suggests that children in working poor families lack health resources, placing them at risk for inadequate access to care.

OBJECTIVES

To examine financial and nonfinancial access and utilization of health services among children in working poor families, and to compare these data with those of children from both nonworking poor and moderate to affluent families.

DESIGN

A cross-sectional study of 13 785 children younger than 18 years.

PARTICIPANTS

Subjects from the 1997 National Health Interview Survey.

MAIN OUTCOME MEASURES

Prevalence and continuity of health insurance coverage, of delayed or missed care, and of unmet care needs; presence and type of usual source of care; and the amount of visits to physicians, emergency departments, and hospitals.

RESULTS

Compared with children of nonworking poor parents and moderate to affluent children, more working poor children were uninsured (22% vs 12% and 5%, respectively; P<.01) and experienced disruptions in insurance coverage (P<.01). After adjusting for other covariates, disparities in insurance coverage and continuity persisted, as did delays in care and unmet care needs; these delays were far higher for the working poor. Although these children had access to a regular source of care and had utilization rates comparable with those of other poor children, they differed markedly from moderate to affluent children on structural access and utilization (adjusted odds ratios, 1.5-3.4).

CONCLUSIONS

Children in working poor families experience far more barriers to care than other children. Health insurance expansions through the Children's Health Insurance Program and Medicaid, which reduce financial and nonfinancial barriers to care, may help correct these disparities.

Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review

PURPOSE

Interest in the effects of neighbourhood or local area social characteristics on health has increased in recent years, but to date the existing evidence has not been systematically reviewed. Multilevel or contextual analyses of social factors and health represent a possible reconciliation between two divergent epidemiological paradigms-individual risk factor epidemiology and an ecological approach.

DATA SOURCES

Keyword searching of Index Medicus (Medline) and additional references from retrieved articles.

STUDY SELECTION

All original studies of the effect of local area social characteristics on individual health outcomes, adjusted for individual socioeconomic status, published in English before 1 June 1998 and focused on populations in developed countries.

DATA SYNTHESIS

The methodological challenges posed by the design and interpretation of multilevel studies of local area effects are discussed and results summarised with reference to type of health outcome. All but two of the 25 reviewed studies reported a statistically significant association between at least one measure of social environment and a health outcome (contextual effect), after adjusting for individual level socioeconomic status (compositional effect). Contextual effects were generally modest and much smaller than compositional effects.

CONCLUSIONS

The evidence for modest neighbourhood effects on health is fairly consistent despite heterogeneity of study designs, substitution of local area measures for neighbourhood measures and probable measurement error. By drawing public health attention to the health risks associated with the social structure and ecology of neighbourhoods, innovative approaches to community level interventions may ensue.

Unfriendly shores: how immigrant children fare in the U.S. health system

The proliferation of poor immigrant children in the United States raises concern about their high uninsurance rates and access to care. We examined the joint effects of health insurance status and place of birth on use of health services by children of the working poor. Of foreign-born children, 52 percent were uninsured and 66 percent had a regular care source, compared with 20 percent and 92 percent, respectively, of native-born children. Foreign-born uninsured children were less likely than their native-born peers were to have a regular care source or to have sought care. Health insurance and immigration policies must act in concert to increase health care access for foreign-born children.

The validity of information on "race" and "Hispanic ethnicity" in California birth certificate data

OBJECTIVE

To evaluate the validity of racial/ethnic information in California birth certificate data.

DATA SOURCES

Computerized birth certificate data and postpartum interviews with California mothers.

STUDY DESIGN AND DATA COLLECTION

Birth certificates were matched with face-to-face structured postpartum interviews with 7,428 mothers to compare racial/ethnic information between the two data sources. Interviews were conducted in Spanish or English during delivery stays at 16 California hospitals, 1994-1995.

PRINCIPAL FINDINGS

The sensitivity of racial/ethnic classification in birth certificate data was very high (94 percent to 99 percent) for African Americans, Asians/Pacific Islanders, Europeans/Middle Easterners, and Latinas (Hispanics). For Native Americans, however, the sensitivity was only 54 percent. The positive predictive value of birth certificate classification of race/ethnicity was high for all racial/ethnic groups (96 percent to 97 percent).

CONCLUSIONS

Despite limited training of birth clerks, the maternal racial/ethnic information in California birth certificate data appears to be a valid measure of self-identified race and Hispanic ethnicity for groups other than Native Americans.

Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors

OBJECTIVE

This study, designed to avoid methodologic limitations of previous research, aimed to identify the important noninsurance barriers to timely prenatal care.

METHODS

We identified a subsample of a cross-sectional statewide representative postpartum survey conducted in California during 1994-1995, focusing on 3071 low-income women with Medi-Cal or private coverage throughout pregnancy.

RESULTS

Twenty-eight percent of those women had untimely care, although only 6% were unaware of their pregnancies during the first trimester. Controlling for numerous sociodemographic factors; knowledge, attitudes, beliefs, and behaviors; stressful life circumstances; and logistic obstacles that might deter seeking or receiving care, the following risk factors for untimely care were significant and experienced by more than one fifth of women: unwanted or unplanned pregnancy (affecting 43% and 66% of women, respectively), no regular provider before pregnancy (affecting 22% of women), and no schooling beyond high school (affecting 76% of women). Transportation problems, affecting 8% of women, appeared to be the only significant logistic barrier to timely care.

CONCLUSION

Improving timeliness of prenatal care among low-income women with third-party coverage is likely to require broad social and health policies that focus on factors affecting women before pregnancy. Assistance with transportation could contribute to more timely care for some low-income women, but programs focusing primarily on other noninsurance barriers during pregnancy might not substantially improve the timeliness of care, at least among low-income women with third-party coverage.

Does membrane lipid profile explain chilling sensitivity and membrane lipid phase transition of spermatozoa and oocytes?

Ram, fowl and bee spermatozoa, and oocytes of cows and zebrafish were used to study lipid membrane profiles, chilling sensitivity and lipid-phase transitions. The integrity of the membranes was determined by carboxyfluorescein diacetate (CFDA) staining following exposure for 15 minutes to low temperatures. Ram and fowl spermatozoa showed different degrees of loss of membrane integrity. Surprisingly, bee spermatozoa did not show any sensitivity to chilling, and their membranes remained intact down to 0 degree C. In bovine oocytes (at the GV stage) chilling injury was very severe at 16 degree C (membrane integrity decreased by 50%). Lipid phase transition (LPT) and membrane fluidity, which were evaluated by Fourier transform infrared (FTIR) microscopy, and fluorescence polarisation, showed phase transitions at the same temperatures as caused damage (between 30 and 12 degree C). The membrane lipid profiles showed high concentrations of polyunsaturated fatty acids (PUFA) in cold-sensitive ram spermatozoa and zebrafish oocytes, but the ratio between PUFA and saturated fatty acids was highest in cold-resistant bee spermatozoa and lowest in cold-sensitive bovine oocytes. These results suggest a close relationship among cold susceptibility, lipid phase transition and lipids profile in animal gametes.

Chilling sensitivity in zebrafish (Brachydanio rerio) oocytes is related to lipid phase transition

Oocytes of zebrafish were used to study chilling sensitivity and membrane lipid phase transitions in tropical fish. The oocytes were divided into two groups: small (without yolk, <0.1mm) and large (with yolk, >0.1mm). After exposure of the oocytes to different temperatures (25, 22, 19, 16, 12, 8, 0, -8+0.5 degree C) for 15 minutes, the integrity of their membranes was determined by carboxyfluorescein diacetate (CFDA) staining. At 16 and 12 degree C, damage was maximum (membrane integrity decreased by 50%) for small and large sizes, respectively. Lipid phase transition (LPT), which was evaluated using Fourier transform infrared (FTIR) microscopy, indicated phase transitions at the same temperatures at which damage was maximal (between 22 and 12 degree C).In another series of experiments, the chilling sensitivity of oocytes taken from zebrafish which had been held at 16 degree C for different periods of time (0, 15, 30, 60 minutes) was determined as described above. In small oocytes membrane integrity decreased after 15 minutes, and in large oocytes integrity decreased after 30 minutes. Chilling sensitivity was also measured in oocytes from zebrafish that had been held at 16 degree C for 30 minutes and then rewarmed to 28 degree C for 2 hours. Despite this recovery period, the integrity of the oocytes remained low. We suggest that chilling sensitivity in zebrafish oocytes is related to lipid phase transition of their membranes and starts at 10 degree C below the physiological temperature

Kinetic and temporal factors influence chilling injury to germinal vesicle and mature bovine oocytes

In this study we examined the effects of low, above freezing temperatures on the viability and functionality of bovine oocytes. Germinal vesicle (GV) stage and in vitro matured oocytes (MII) were exposed to various combinations of time (15 and 60 min) and temperature (4, 16, 23, and 39 degrees C). After being treated, the ability of oocytes to undergo maturation and fertilization in vitro was examined, as well as their viability assayed by two fluorescent probes, fluorescein diacetate (FDA) and 5-carboxyfluorescein diacetate (cFDA). Cooling GV oocytes to 16 degrees C for 15 min reduced the fertilization rate by more than 40%, compared with those left at 39 degrees C. Surprisingly, cooling oocytes to 4 degrees C reduced the fertilization rate by only 10% compared with control. Exposing GV oocytes to temperatures below 23 degrees C reduced their viability. Similar to the reduction in fertilization, the viability of GV oocytes after exposure to 16 degrees C was reduced by more than 50%, whereas exposure to 4 degrees C reduced it by only 9%. Viability measurements using FDA and cFDA gave comparable results and showed a similar trend. The viability of MII oocytes and of GV oocytes pretreated with butylated hydroxytoluene, following exposure to low temperatures, was higher compared with that of GV controls. We interpret these results as indicating chilling effects on membrane integrity. Improving the chilling resistance of bovine oocytes may facilitate their short- and long-term preservation.

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.

Validity of insurance information on California birth certificates

OBJECTIVES

This study assessed the validity of health insurance information on California birth certificates.

METHODS

Insurance information from birth certificates and linked face-to-face interviews was compared for 7428 postpartum women in California.

RESULTS

There was excellent agreement between insurance information in birth certificate and interview data, especially when capitated plans were grouped with all other private coverage. Analyses using both data sources produced similar estimates of the likelihood of untimely prenatal care according to type of insurance coverage.

CONCLUSIONS

Birth certificate data including insurance information appear to be an appropriate resource for examining both the extent of coverage for maternity care and associations between prenatal care use and insurance status.

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.

Risk behavior and HIV seroprevalence among injecting drug users in Rio de Janeiro, Brazil

OBJECTIVE

To characterize HIV seroprevalence and risk behavior among injecting drug users (IDUs) in Rio de Janeiro, Brazil, between 1990 and 1996.

DESIGN

We report data from three separate cross-sectional samples of IDUs in Rio de Janeiro: the World Health Organization (WHO) sample (n = 479), the Proviva sample (n = 138) and the Brasil sample (n = 110). These data provide the most comprehensive view available, to date, of this understudied population in Rio.

METHODS

Demographic characteristics, HIV/AIDS risk behavior and HIV seroprevalence were compared across the three samples and combined analyses were performed to determine the factors associated with injecting risk behavior, sexual risk behavior and HIV seropositivity.

RESULTS

The overall HIV seroprevalence among IDUs was 25%. Two encouraging findings of the present analysis were the lower levels of needle-sharing among participants recruited in the latest years (1995-1996) and the lower HIV seroprevalence in the Proviva sample composed mainly of less educated, poorer IDUs living in deprived neighborhoods. No trends toward safer behavior were found for sexual risk, younger age being the principal factor associated with high risk.

CONCLUSIONS

Levels of needle-sharing and sexual risk among IDUs in Rio remain high, demonstrating the urgent need to increase the limited preventive measures undertaken so far. Seroprevalence levels for HIV remain significantly lower in the most deprived sample, arguing for the fundamental importance of prompt and effective prevention strategies to keep infection rates from rising among the poorest and largest strata of Rio's IDUs.

Problems associated with early discharge of newborn infants. Early discharge of newborns and mothers: a critical review of the literature

OBJECTIVE

To determine whether research supports the advisability of early discharge of healthy newborns and mothers.

METHODS

Critical review of English-language literature cited in the Index Medicus or the International Nursing Index.

FINDINGS

No adequately designed studies have examined discharge before 48 hours after delivery without additional postdischarge services. Few studies have examined the consequences of recommending a clinic visit within the first days after discharge; studies of this practice among low-income populations found high no-show rates. Some small studies suggest that early discharge is likely to be safe for selected populations at low psychosocial, socioeconomic, and medical risk, with careful antenatal screening and preparation and multiple postpartum home visits. Some studies suggested adverse outcomes associated with early discharge even with early follow-up.

CONCLUSIONS

Published research provides little knowledge of the consequences of short maternal/newborn hospital stays or varying postdischarge practices for the general population. The studies that have concluded that early discharge was safe were applied under restricted circumstances or were too small to detect clinically significant effects on important outcomes. Further research is needed to inform clinical and reimbursement policy on health services in the first days of life and parenting. Rigorous studies of sufficient size are needed to examine the impact of different hospital stays and different postdischarge practices on a range of outcomes for mothers and newborns in diverse populations and settings. Given a priori concerns, decisions on neonatal/obstetric discharge planning should be made cautiously.

Potential acceptability of ovulation detection kits and RU-486 at two college campuses

Two innovations in fertility research may expand birth control options in the United States. Ovulation detection kits, used alone or in conjunction with barrier methods of contraception, could be used to chart the fertile period. RU-486, when used in conjunction with a prostaglandin, induces early abortion, providing an alternative to conventional vacuum aspiration abortion. To measure the hypothetical acceptability of these methods, the authors surveyed 710 women at two college campuses in California regarding potential use of ovulation detection kits and RU-486. Seventy-one percent of the women in the final sample indicated an interest in using ovulation kits. Of these women, most (72%) were interested in using an ovulation detection kit as a supplement to barrier methods, and 22% indicated they would consider the kit as a sole method of birth control. More than 68% of the women in the sample indicated they would choose an abortion if faced with an unwanted pregnancy, and 60% would hypothetically choose RU-486 in preference to a conventional pregnancy termination. The most frequently cited reason for preferring RU-486 rather than conventional methods of abortion was to avoid the risks associated with the vacuum aspiration technique.

Protein kinase C-dependent and -independent pathways mediate epidermal growth factor (EGF) effects in human endometrial adenocarcinoma cell line KLE

The role of EGF in the proliferation of the poorly differentiated endometrial adenocarcinoma cell line (KLE) was examined. EGF (10 ng/ml) and the tumor promoter, protein kinase C agonist, phorbol 12-myristate 13-acetate (PMA) were potent stimulators (P < 0.01) of DNA synthesis in this cell line as determined by [3H]thymidine incorporation into DNA. Staurosporine, a protein kinase C inhibitor, partially blocked the EGF effects on [3H]thymidine incorporation. Similarly, downregulation of protein kinase C also failed to completely abolish EGF effect on DNA synthesis and cell division. These results suggest that in the KLE cell line EGF stimulation of cell growth is exerted through both protein kinase C-dependent and -independent pathways.

Nuclear imaging and the assessment of human Fc receptor function: studies in systemic lupus erythematosus

In vivo immune clearance of immunoglobulin G sensitized autologous erythrocytes (rbc) was studied in nine patients who fulfilled American Rheumatism Association (ARA) criteria for systemic lupus erythematosus (SLE). Opsonized rbc were radiolabelled with technetium 99. The rate of radioactive blood clearance was measured, as was organ-specific radioactive uptake utilizing area-of-interest (AOI) measurements in a computerized scintigraphic imaging system. It was shown that dynamic quantitation of an AOI corresponding to the heart generated time-activity curves which approximated blood-clearance curves. Calculation of first order clearance (min per 50% decrease in counts) showed a highly significant correlation between rates derived from heart AOI curves and those derived from blood-clearance curves (r = 0.9483, P = 0.0003). Clearance curves showed a monoexponential slope in most patients. Further exploration of organ-specific AOI curves showed that percent splenic uptake and the nature of the splenic uptake curves varied between patients. These studies point toward a variable splenic role in Fc receptor function for SLE patients and further demonstrate the utility of nuclear imaging in studying immune clearance.

Epidural angiolipoma with spinal cord compression

A case of epidural angiolipoma is reported. This tumor rarely occurs in the spinal canal. The most common location is in the thoracic region, and its histogenesis is probably congenital.

Cytosolic calcium and the action of vasopressin in toad urinary bladder

The effects of experimental procedures believed to increase cytosolic calcium on basal and vasopressin-stimulated osmotic water flow and transepithelial sodium transport were examined in the toad urinary bladder. Exposure of isolated toad bladders to quinidine, calcium ionophores (A23187, X537A), or low-sodium or potassium-free serosal solutions resulted in a dose-dependent decrease in the hydrosmotic response to vasopressin or exogenous adenosine 3',5'-cyclic monophosphate (cAMP). The degree of inhibition of cAMP-induced water flow induced by low-sodium or potassium-free serosal bathing media varied, and in a similar manner, with the serosal calcium concentration. The effects of quinidine sulfate (2 X 10-4 M), X537A (2 X 10(-5) M), and low serosal sodium (20 mM), but not that of A23187 (10(-5) M), were readily reversible. Exposure to quinidine (4 X 10(-4) M), A23187 (10(-5) M), X537A (5 X 10(-6) M), or low serosal sodium (2 mM) also inhibited the basal short-circuit current (SCC). Vasopressin, 4-20 mU/ml, completely overcame the inhibition of the SCC induced by quinidine, A23187, or low serosal sodium, but a submaximal dose of hormone (4 mU/ml) failed to fully reverse the inhibitory effect of X537A, 5 X 10(-6) M. These results are consistent with the view that 1) a Na-Ca exchange process operates across the basolateral surface of the granular epithelial cells of the toad urinary bladder in vivo, and 2) the level of free calcium in the granular cell cytosol plays a modulatory role in the control of apical membrane water and sodium permeability by vasopressin, and in the regulation of the basal rate of transepithelial sodium transport.

Epileptic seizures as a cause of unilateral pulmonary edema

We report three patients with recurrent tonic-clonic seizures associated with unilateral pulmonary edema. Each lung was involved on separate occasions in one patient. The mechanisms of seizure-related pulmonary edema are discussed. Although accurate diagnosis of unilateral postictal pulmonary edema may be difficult because of its rarity, not all pulmonary abnormalities that follow seizures represent pneumonia.

Anion transport inhibitors: effects on water and sodium transport in the toad urinary bladder

Acidification of the medium bathing the serosal surface of the toad urinary bladder results in impairment of the water permeability response to vasopressin. The magnitude of the hydrosmotic response to a maximal concentration of either vasopressin or the cyclic nucleotide analogue 8-(p-chlorophenylthio)-cyclic 3',5'-adenosine monophosphate (C1PhS-cAMP) was progressively reduced when serosal bath pH was decreased from 8.5 to 6.5. The disulfonic stilbenes SITS and DIDS and the diuretic furosemide, agents known to interfere with anion transport and with the regulation of intracellular pH in other tissues, inhibited the water flow response to vasopressin and C1PhS-cAMP in a pH-dependent manner when added to the serosal bathing medium. Inhibition of the hydrosmotic response to 10(-5) M C1PhS-cAMP was estimated to be half-maximal at 1.5 X 10(-4) M SITS, 2 X 10(-5) M DIDS, and 1 X 10(-5) M furosemide. The degree of inhibition induced by the anion transport inhibitors varied inversely with the concentration of exogenous cyclic nucleotide. SITS, DIDS, and furosemide had no effect on either basal or vasopressin-stimulated short-circuit current at serosal pH 8.5; all three agents inhibited basal short-circuit current at pH 7.1 but had no effect on the natriferic response to vasopressin. These results are consistent with the view that changes in intracellular hydrogen ion and/or anion concentration can selectively inhibit the increase in water permeability elicited by vasopressin at a step(s) distal to the generation of cAMP.

Studies on the spectrin-like protein from the intestinal brush border, TW 260/240, and characterization of its interaction with the cytoskeleton and actin

The terminal web of the intestinal brush border contains a spectrin-like protein, TW 260/240 (Glenney, J. R., Jr., P. Glenney, M. Osborne, and K. Weber, 1982, Cell, 28:843-854.) that interconnects the "rootlet" ends of microvillar filament bundles in the terminal web (Hirokawa, N., R. E. Cheng, and M. Willard, 1983, Cell, 32:953-965; Glenney J. R., P. Glenney, and K. Weber, 1983, J. Cell Biol., 96:1491-1496). We have investigated further the structural properties of TW 260/240 and the interaction of this protein with actin. Salt extraction of TW 260/240 from isolated brush borders results in a loss of terminal web cross-linkers primarily from the apical zone directly beneath the plasma membrane. Morphological studies on purified TW 260/240 using the rotary shadowing technique confirm earlier results that this protein is spectrin-like and is in the tetrameric state in buffers of low ionic strength. However, examination of TW 260/240 tetramers by negative staining revealed a molecule much straighter and more uniform in diameter than rotary-shadowed molecules. At salt concentrations at (150 mM KCl) and above (300 mM KCl) the physiological range, we observed a partial dissociation of tetramers into dimers that occurred at both 0 degree and 37 degrees C. We also observed (in the presence of 75 mM KCl) a concentration-dependent self-association of TW 260/240 into sedimentable aggregates. We have studied the interaction of TW 260/240 with actin using techniques of co-sedimentation, viscometry, and both light and electron microscopy. We observed that TW 260/240 can bind and cross-link actin filaments and that this interaction is salt- and pH-dependent. Under optimum conditions (25-75 mM KCl, at pH 7.0) TW 260/240 cross-linked F-actin into long, large-diameter bundles. The filaments within these bundles were tightly packed but loosely ordered. At higher pH (7.5) such bundles were not observed, although binding and cross-linking were detectable by co-sedimentation and viscometry. At higher salt (greater than 150 mM KCl), the binding of TW 260/240 to actin was inhibited. The presence of skeletal muscle tropomyosin had no significant effect on the salt-dependent binding of TW 260/240 to F-actin.

Actin filaments and vasopressin-stimulated water flow in toad urinary bladder

Vasopressin increases the water permeability of the apical membrane of the granular epithelial cells of the toad urinary bladder. Cytochalasin B inhibits this action of the hormone, indicating that microfilaments may play a role in the water permeability response. We have extended previous functional studies with cytochalasin B and have demonstrated that dihydrocytochalasin B, a more specific inhibitor of actin filament elongation, similarly diminishes the hydrosmotic response to vasopressin. Biochemical studies of isolated epithelial cells indicate that an actin-like protein accounts for about 10% of the soluble protein of the epithelium. Morphological studies of whole toad bladders incubated with heavy meromyosin conclusively demonstrate that actin is a component of the epithelial cells and that actin-containing filaments are associated with both plasma membranes and cytoplasmic organelle membranes. Taken together, these findings provide strong, albeit indirect, evidence that actin microfilaments play a functional role in the hormone-induced increase in water permeability in the toad urinary bladder.

Radiographic findings in congenital lead poisoning

Because lead crosses the placenta throughout pregnancy, the fetus is at risk for lead poisoning. A full term, asymptomatic child was born with congenital lead poisoning secondary to maternal pica. Radiographic findings of a dense cranial vault, lead lines, and delayed skeletal and deciduous dental development were noted at birth. After chelation therapy, when the patient was seven months old, radiographs revealed normal skeletal maturation. Tooth eruption did not occur until 15 months of age. Newborn infants with these radiographic findings should be screened for subclinical, congenital lead poisoning.