Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Analysis of pulmonary embolus size at the time of recurrence compared with presentation: a single-centre retrospective study

Essentials Size of pulmonary embolus (PE) at the time of recurrence compared with first event is unstudied. In a retrospective cohort of patients we compared PE size at recurrence versus the initial PE. Rates of massive PE at recurrence were low whether the first PE was massive or unmassive. Studies to determine PE size and severity at recurrence when anticoagulation is stopped are needed.

SUMMARY

Background The size of recurrent pulmonary embolus (PE) in relation to a prior event could be a factor in deciding whether to continue anticoagulation. There are no published data on this subject to help with counselling patients. Objectives To determine whether size of a first PE predicts the size at recurrence. Patients and methods This was a retrospective cohort study of consecutive patients with recurrent PE over 25 months at a single tertiary center. In confirmed cases the sizes of first and recurrent PEs were grouped into radiologically non-massive PE (RNMPE) or radiologically massive PE (RMPE) if there was bilateral main pulmonary artery thrombus, saddle PE or right ventricular strain on the computerized tomography pulmonary angiogram. Results Sixty-three patients were included in the study (37 exclusions). Thirty-seven patients were men and 26 women, with a median age of 72 years; 33.3% of PEs were unprovoked. Patients whose first PE was an RNMPE (46/63 or 73% of patients) had a 15.2% (95% confidence interval [CI], 7.6-28.2%) chance of RMPE at recurrence and a 32.6% (95% CI 20.9-47.0%) chance of having a larger PE at recurrence, whereas those who presented first with an RMPE (17/63 or 27% or patients) had a 17.6% (95% CI, 6.2-41.0%) chance of RMPE at recurrence (odds ratio, 1.19; CI, 0.27-5.27). Conclusions Risk of a massive PE at recurrence is low (and similar) irrespective of the size of the first PE in this single study. Further studies are warranted as this could help in decisions on long-term anticoagulation.

Female crickets assess relatedness during mate guarding and bias storage of sperm towards unrelated males

Recent evidence shows that females exert a post-copulatory fertilization bias in favour of unrelated males to avoid the genetic incompatibilities derived from inbreeding. One of the mechanisms suggested for fertilization biases in insects is female control over transport of sperm to the sperm-storage organs. We investigated post-copulatory inbreeding-avoidance mechanisms in females of the cricket Teleogryllus oceanicus. We assessed the relative contribution of related and unrelated males to the sperm stores of double-mated females. To demonstrate unequivocally that biased sperm storage results from female control rather than cryptic male choice, we manipulated the relatedness of mated males and of males performing post-copulatory mate guarding. Our results show that when guarded by a related male, females store less sperm from their actual mate, irrespective of the relatedness of the mating male. Our data support the notion that inhibition of sperm storage by female crickets can act as a form of cryptic female choice to avoid the severe negative effects of inbreeding.

Island hopping introduces Polynesian field crickets to novel environments, genetic bottlenecks and rapid evolution

Teleogryllus oceanicus, a cricket native to Australia, was introduced to Hawaii where it encounters a novel natural enemy responsible for their recent rapid evolutionary loss of singing ability. To explore how genetic diversity varies across their broad range, their mode of introduction to Hawaii and nonadaptive influences on the sexual signalling system, we assessed variation at seven microsatellite loci in 19 Australian and island populations. Genetic variability was highest in Australia, intermediate in Oceania and lowest in Hawaii, and differentiation among local populations was a clear function of geographical distance. Hawaiian populations are most closely related to those from the Society Islands and Cook Islands, and a neighbour-joining tree based on D(A) is consistent with movement by Polynesian settlers. We found evidence of bottlenecks in six island populations (including three Hawaiian populations), supporting previous findings in which bottlenecks were implicated in the crickets' loss of singing ability.

Seasonal Variation and Regional Distribution of Cleft Lip and Palate in Zambia

Objective:

To assess variations in seasonality and regional distribution of orofacial clefts in babies born in Zambia.

Design:

A retrospective chart review was done using records of all cleft procedures performed by the only plastic surgeon in Zambia (G.J.). Delivery data from the University Teaching Hospital (UTH) were also examined to estimate the birth prevalence of orofacial clefts (55,108 live births between 2001 and 2005).

Patients:

All cleft patients operated in Zambia from 2000 to 2006 (413 patients).

Results:

A low birth prevalence of clefts (1/4239 live births) was found using UTH delivery data. Surgical data showed no difference for the frequency of one gender over another overall (M:F ratio is 1.04; p  =  .70). More bilateral clefts occurred in cleft lip and palate (CLP) patients than in cleft lip (CL) patients (p < .01), and more unilateral left-sided clefts occurred in CL than in CLP patients (p  =  .03). The data reflected seasonal variation in month of birth of cleft lip with or without cleft palate (CL±P) patients (p < .01), with a peak in April and May and more births in March through August (57.2%) than in September through February (42.8%). There was regional variation in cleft births among the nine Zambian provinces (p < .01).

Conclusions:

This study shows seasonal variation in clefts that may be explained, at least in part, by environmental factors affecting the development of CL±P. Access to treatment is likely the major determinant of regional disparity in clefts. These results provide a basis for further epidemiological studies of orofacial clefts in Zambia.

A survey of Canadian general surgery residents' interest in international surgery

OBJECTIVE

This survey of Canadian general surgery residents was designed to determine their interest level, past experiences and awareness of opportunities in the field of international surgery.

METHODS

A web-based national survey in both French and English was sent to all Canadian general surgery residents. This survey comprised 24 questions regarding demographics, education, previous international experience, interest level and perceived opportunities in international surgery.

RESULTS

A 27% response rate revealed a high level of interest in international surgery among Canadian general surgery residents but a low level of awareness of the opportunities and relevant organizations.

CONCLUSION

Further initiatives are needed to increase international surgery awareness and opportunities among general surgery residents.

“What do kids know”: A survey of 420 Grade 5 students in Cambodia on their knowledge of burn prevention and first-aid treatment

INTRODUCTION

Cambodia is a developing country of 13 million people where there are an estimated 20,000 burns and 2000 burn deaths annually. Two thirds of the burns occur to children under the age of 10 years. The purpose of this study was to determine the knowledge of burn prevention and first aid for burns in Grade 5 Cambodian school children, as baseline information to design a burn prevention campaign.

METHODS

A 34-question survey regarding burn prevention and first-aid treatment for burn injuries was developed. Additional questions on TV watching habits were included to determine the feasibility of a targeted TV burn educational campaign. The survey was translated into Khmer language and tested on a trial class for accuracy and ease of administration. After obtaining the school director's permission and children's consent the survey was administered by Canadian medical students helped by trained translators and teachers to Grade 5 students from eight different elementary schools in the Kampot province.

RESULTS

A total of 420 students were surveyed. Average age was 12.5 years (range 9-17 years) and 55% were females. Seventy-four percent routinely cared for other children. Only 52% had TV at home but still 78% managed to watch TV for an average 2h per day. Even though 36% of students indicated they had received information about burn prevention and first aid, only 13% mentioned application of cool water as initial treatment, only 7% knew to roll on the ground if their clothes caught fire, and nearly 50% would pour water on a burning pot of oil. Half of students indicated that they would not believe a TV message promoting application of cold water on acute burns. Top reasons given were parental influence, belief in other treatments, and not trusting TV messages. Interestingly, 62% of these skeptics would change their mind if the TV message was endorsed by an authority figure such as a physician, teacher, parent, or the Ministry of Health. A set of five Public Service Announcements for Cambodian TV were developed and produced based on the results of this survey.

CONCLUSIONS

This survey identified significant inadequacies in Cambodian children's knowledge about burn prevention and first aid and suggested that a televised burn prevention campaign could be an effective method to improve their knowledge, especially if it was endorsed by an authority figure.

Vascular endothelial growth factors C and D represent novel prognostic markers in colorectal carcinoma using quantitative image analysis

BACKGROUND/AIMS

Vascular endothelial growth factor C (VEGF-C) and vascular endothelial growth factor D (VEGF-D) are potent lymphangiogenic and angiogenetic mediators in many kinds of tumors. However, the exact impacts of VEGF-C and VEGF-D on the prognosis of colorectal cancer (CRC) remain elusive. The aims of this study were to demonstrate the expression of VEGF-C and VEGF-D and to correlate their expression levels with clinicopathological factors and long-term survival in patients with CRC.

PATIENTS AND METHODS

Between January 1996 and January 1998, 69 patients with pathologically confirmed CRC who received routine follow-up at the Ruijin Hospital were included in this study. VEGF-C and VEGF-D protein expression and microvessel density of 69 surgical specimens were assessed by immunohistochemistry, with 20 samples of normal colorectal tissues as controls. All patients were followed up for 108 months or until death. The Immunohistochemical stains were quantified and analyzed by means of a Zeiss Axioplan 2 imaging analysis system.

RESULTS

The protein expression of VEGF-C and VEGF-D in tumor tissues was much higher than that in normal colorectal tissues (p < 0.01). The VEGF-C expression significantly correlated with lymph node metastasis (p = 0.011) and clinical stages of CRC (p < 0.01). The VEGF-D expression correlated with patient ages (p = 0.013), depth of tumor invasion (p = 0.013), and lymph node metastasis (p = 0.028). The expression of VEGF-C and VEGF-D was significantly correlated with the microvessel density. Both overall survival and disease-free survival at 108 months were significantly lower in the CRC patients with a high VEGF-C and/or a high VEGF-D expression, and the patients with a high expression of both VEGF-C and VEGF-D had the shortest overall survival and disease-free survival when compared with other patients.

CONCLUSION

The VEGF-C or VEGF-D expression was significantly correlated with lymph node metastasis and long-term prognosis and could be applied as prognostic markers in CRC.

Characteristics of burn patients at a major burn center in Shanghai

In China, burns are becoming a major cause of morbidity and mortality with large societal and economic implications. To date, there is little epidemiological data on burns in China to direct prevention efforts. This study describes the characteristics of burn patients admitted to a major burn center in Shanghai using a burn registry developed in Toronto, Canada. A retrospective review of burn patients discharged from the Shanghai's Rui Jin Hospital Burn Unit, between March 1st 2002 and April 30th 2003, was conducted. Of 527 patients discharged, 307 were acute burn patients and 302 (98.4%) had complete data to be included in the study. There were 214 (71%) males and 88 (29%) females with a male to female ratio of 2.4:1. The median age was 30 years, and the median total body surface area burned was 10%. The majority of burns occurred at work (58%), and the most frequent etiology was flames (39%) followed by scalds (31%) and contact with hot objects (15%). Sixteen (5%) patients had inhalation injury and six (2%) patients died. There were 70 (23%) children (0-14 years), 221 (73%) adults (15-59 years) and 11 (4%) seniors (60 years and above). Children had more scald burns (83%) and the majority (83%) occurred at home. Adults had more flame burns (46%) and the majority (79%) were work-related injuries. Seniors had more flame burns (73%) and the majority (55%) occurred in domestic incidents. Seniors had deeper burns (13%, p=0.005), required more escharotomies (55%, p=0.002), required more operations (2, p=0.051) and had higher mortality (36%, p<0.001) than other age groups. These results provide compelling evidence for performing population-based studies to identify risk factors that are susceptible to modification in each age group.

Characteristics of 1494 pediatric burn patients in Shanghai

To analyze the epidemiological characteristics of pediatric burn patients in Shanghai and to determine the targets for a pediatric burn prevention program, a retrospective review of all medical records of acute pediatric burn patients (age</=14 years old) admitted to the Burn Center of the Ruijin Hospital between January 1980 and December 2002 was performed. Patient demographics, etiology of burn, mechanism of injury, extent and anatomical areas burned, number of operations, and length of hospital stay were recorded. A total of 1494 pediatric burn patients were admitted. Six hundred eighty-seven (46%) patients were from the migrant population (non-registered population of temporary workers from rural areas outside of Shanghai). Scalding was the main cause of pediatric burns in the age groups. Children 0-3-year-old were the most common victims of scalding, chemical burns, and contact burns. Domestic burns resulted in 1293 (86.5%) injuries followed by burns occurring while playing in public. The incidence of domestic burns has increased since the beginning of the study period, while the incidence of burns while playing in public has decreased. The median total body surface area was 4% for mild burns, 10% for moderate burns, and 18% for extensive burns. Predominant areas involved were the head, neck, anterior trunk, and right lower limb. Most children received conservative treatment, and their mean hospital stay was 16.1+/-12.2 days. There were 17 (1.1%) deaths, mostly due to sepsis (82.4%). Migrant children are the majority of burn victims since 1996. The education of burn prevention should focus on the migrant population in an industrializing city.

Building surgical research capacity in Africa: the Ptolemy Project

The authors describe the Ptolemy Project, a recently developed model of electronic access to medical literature for surgeons in developing countries.

Relevance of Electronic Health Information to Doctors in the Developing World: Results of the Ptolemy Project’s Internet-based Health Information Study (IBHIS)

The aim of this study was to determine the current usage, relevance, and preferences for electronic health information (EHI) in the participant surgeons' clinical, research, and teaching activities. The Internet-Based Health Information Survey (IBHIS) was conducted from August to December 2003. Thirty-seven doctors (primarily practicing in East Africa) participated, all of whom had been using the Ptolemy resources for at least 6 months. Survey questions concerned time spent reading medical literature, preferred information sources, preferred type of publication, relevance, preference for western versus local medical literature, and academic productivity. Among the 75 eligible participants, 37 (48%) responded. From these responses it was found that African surgeons with access to EHI read more than articles than they did before they had such access, and they find that the information obtained is highly relevant to their clinical, teaching, and research activities. They prefer electronic journals to textbooks and are more inclined to change their practice based on information found in western journals than local journals. Ptolemy resources helped the respondents who reported academic work write a total of 33 papers for presentation or publication. Overall, access to EHI enables doctors in Africa to read more, is relevant, and contributes directly to academic productivity; thus Western medical literature is useful in the developing world, and EHI delivery should continue to expand.

SNAT expression in rat placenta

Amino acid transport System A (SysA) activity is present within the rodent and human placentas. Inhibition of this transport system is associated with fetal growth retardation. Several cDNAs encoding SysA transport proteins have been discovered, and their presence documented within the human placenta. We have demonstrated the presence of mRNA encoding three of these transporters, SNAT1, 2, and 4 within the rat placenta over the final third of gestation. Abundance of these mRNA species increases from day 14 to day 20 of gestation. Immunohistochemistry demonstrates the presence of SNAT1 and 2 within the placental labyrinth at both days 14 and 20. Transport proteins are also present within marginal giant cells and, for SNAT1, within fetal endothelium. In conclusion, several proteins capable of SysA transport activity are present within the rodent placenta. mRNA expression increases over the final third of gestation, coincident with the period of greatest need for fetal amino acid delivery.

The burden of orthopaedic disease in developing countries

The global burden of musculoskeletal disease in low and middle-income countries is large, growing, and neglected. While there is considerable funding for the control of communicable disease, there has been little attention paid to either the prevention or the treatment of orthopaedic problems in developing countries. "Safe Roads" was the theme for World Health Day 2004, and this paper examines the magnitude of injury in low and middle-income countries, as well as the motors powering its growth, and addresses the balance between the prevention and the treatment of injuries. Finally, it calls upon orthopaedic surgeons in developed countries to build partnerships with their colleagues in less developed countries to improve clinical care, teaching, and research aimed at reducing the global burden of injury.

Acid burns from personal assault in Uganda

Acid burns from assault represent a substantial and neglected proportion of burn injuries in the developing world. A retrospective chart review was conducted to assess the frequency of acid burns in relation to total burns requiring admission in Kampala, Uganda. Seventeen percent of the adult burns admitted at New Mulago hospital over an 18-month period resulted from acid assault. Patients had a mean age of 33.1 years, with a male to female ratio of 1.1:1. The average extent of injury was 14.1% total body surface area (TBSA), commonly involving the face (86.7%), head and neck (66.7%), upper limbs (60.0%) and chest (53.3%). Thirty-three percent of patients suffered partial or complete blindness. Mean length of stay in hospital was 49.5 days and all patients survived. Patterns of assault followed two common trends: attacks during robberies (46.7%), and attacks associated with domestic disputes (33.3%). The Ugandan pattern is contrasted with patterns reported from Bangladesh, Cambodia and Jamaica with a view to understanding the social context underlying such assaults. Prevention of these hideous injuries will require further understanding of their underlying social and cultural determinants. Serious questions remain whether public education programs will reduce the incidence of acid assault or increase it by giving potential assailants an idea they did not have before.

Regulation of glutamate transport and transport proteins in a placental cell line

We utilized HRP.1 cells derived from midgestation rat placental labyrinth to determine that the primary pathway for glutamate uptake is via system X, a Na(+)-dependent transport system. Kinetic parameters of system X activity were similar to those previously determined in rat and human placental membrane vesicle preparations. Amino acid depletion caused a significant upregulation of system X activity at 6, 24, and 48 h. This increase was reversed by the addition of glutamate and aspartate but not by the addition of alpha-(methylamino)isobutyric acid. Immunoblot analysis of the three transport proteins previously associated with system X activity indicated a trend toward an increase in GLT1, EAAC1, and GLAST1 immunoreactive protein contents by 48 h; cell surface expression of the same was enhanced by 24 h. Inhibition analysis suggested key roles for EAAC1 and GLAST1 in basal anionic amino acid transfer, with an enhanced role for GLT1 under conditions of amino acid depletion. In summary, amino acid availability as well as intracellular metabolism regulate anionic amino acid uptake into this placental cell line.

Minimizing blood loss in burn surgery

BACKGROUND

Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound outcome in burn surgery.

METHODS

An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds.

RESULTS

Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p = 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outcome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%.

CONCLUSION

The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

Detection of p56(lck) kinase activity using scintillation proximity assay in 384-well format and imaging proximity assay in 384- and 1536-well format

p56(lck) is a lymphocyte-specific tyrosine kinase that plays an important role in both T-cell maturation and activation. We have developed a homogeneous assay in which p56(lck) catalyzes the transfer of the gamma-phosphate group from [gamma-(33)P]ATP to a biotinylated peptide substrate. The labeled peptide is then captured on a streptavidin-coated scintillation proximity assay (SPA) bead or imaging proximity bead. The SPA is counted in a microplate scintillation counter and the imaging proximity assay is counted in a charge-coupled device-based imaging system called LEADseekertrade mark, recently launched as a homogeneous imaging system by Amersham Pharmacia Biotech. We show, via time-dependence assays and inhibitor studies, that this assay can be performed in 1536-well microplate format using imaging proximity as the method of detection. The results compare favorably with the same assay performed in 384-well microplate format using both SPA and imaging proximity as the detection methods. From this study, we conclude that a kinase assay can be performed in 384- and 1536-well format using imaging as the detection method, with significant time savings over standard scintillation counting. In addition, we show cost saving advantages of 1536- over 384-well format in terms of reagent usage, higher throughput, and waste disposal.

Weaning--a nursing challenge

Weaning a patient from mechanical ventilation and then to extubation is a challenge for critical care nurses who play a vital role in assessing a patient's readiness for weaning and managing the weaning trials. Traditionally, critical care nurses perform the process, but only under the direction and supervision of intensivists. This team approach is important but can lead to delays. I believe that with clearly defined boundaries a critical care nurse could expedite the weaning process of a patient from mechanical ventilation. An Intensive Care Unit protocol, which provides a valid framework from which professional advanced nurse clinicians could work, would give increased autonomy and legitimacy, avoiding unnecessary delays.

The Tumescent Technique for Bloodless Breast Reduction

M Beveridge, M Bell. The tumescent technique for bloodless breast reduction. Can J Plast Surg 1994;2(3):121-124. The tumescent technique for reduction mammaplasty provides a safe, reliable and inexpensive way to reduce intraoperative blood loss in reduction mammaplasty. The results of a study involving 64 consecutive patients operated on by the same surgeon are presented. Initial subjective experience with the infiltration of large volumes of very dilute anaesthetic solution deep in the breast along the planned incision lines suggested that the technique significantly reduced blood loss. To confirm this. 23 consecutive cases were operated upon without infiltration and the next 20 cases were done with infiltration of 250 mL of 0.1 % lidocaine with 1:1,000,000 adrenaline. Preoperative hemoglobin was compared with that obtained at an office visit on the seventh postoperative day. The difference in the drop in hemoglobin observed in the two groups was significant at the P<0.02 level; however, the difference was most pronounced in the group in whom a smaller volume of tissue was removed. Accordingly in the next phase of the study the volume of solution to be injected was calculated in relation to body weight. When 10 mL/kg body weight of solution was injected there was dramatically less bloodloss compared with the control group (P<0.01). Patients experienced no ill effects attributable to the injection: there were no significant postoperative hematomas nor any adverse effect on wound healing.

Reading illustrated science texts: a micro-computer based investigation of children's strategies

Research has shown that the effect of illustrations on children's learning of science is related to ability. This study examines the hypothesis that children who show different levels of success in a learning task will employ different strategies in their picture-text processing. One hundred and eighty 14 year-old children were required to learn three illustrated science topics of different levels of difficulty which were presented to them on a BBC micro-computer. The computer was programmed to record the time spent on each sentence and each picture, as well as the point in the text at which the picture was accessed. Post hoc testing enabled the children to be divided into six groups according to their success rates on the learning tasks. Significantly longer times were spent looking at the pictures as the topics increased in difficulty; also the amount of time spent looking at pictures increased as the learning of the children decreased. For every second the least successful children spent accessing pictures, they spent about four seconds reading the text; for the most successful children this ratio was about one-to-six. The least successful children also accessed the pictures significantly more frequently than the most successful. The different strategies used by the children are discussed in terms of what is known about their differential learning gains from illustrated texts.

Language and social behaviour in severely educationally subnormal children

There is a strong positive relationship between age and the number of social interactions a child is likely to initiate during a typical classroom free-play period. The type of interaction which shows the largest increase is verbally initiated child-child interactions. Verbally initiated child-teacher interactions also increase with age, though not so markedly as child-child interactions. There appears to be no significant change in non-verbal initiations of interactions with age, either to the teacher or to peers. These results give support to the use of observational techniques for language assessment in that they give further information about the growth of productive language skills as reported in a population survey of language abilities in mentally handicapped school children.