An evaluation of intracapsular lens extraction and transcorneal lens reduction for treatment of anterior lens luxation in dogs

OBJECTIVE

The aim of the study was to evaluate success rate, complications, and outcomes in dogs with anterior lens luxation (ALL) treated with intracapsular lens extraction (ICLE) or transcorneal lens reduction (TCLR).

PROCEDURE

Medical records of dogs with ALL undergoing ICLE or TCLR from 2014 to 2021 were reviewed. Signalment, presenting complaint, history, ophthalmic examination findings, short-term complications, and outcomes were analyzed.

RESULTS

There were 20 ICLEs and 31 TCLRs; however, some cases were included in both groups. One ICLE was unsuccessful and four had undergone TCLR first, leaving 15 ICLEs. Three TCLRs were unsuccessful, four were lost to follow up, and three subsequently underwent ICLE due to recurrent ALL, leaving 21 TCLRs. Anterior uveitis was more common following ICLE than TCLR, p < .001 The frequencies of other short-term complications (post-operative hypertension and corneal ulceration) were not statistically different between groups. Median follow-up was 256 and 48 days for ICLE and TCLR, respectively. Vision was retained in 7/10 (70%) eyes following ICLE and 4/9 (44%) eyes following TCLR, p = .34. Enucleation was recommended for fewer eyes following ICLE (2/15 [13%]) than TCLR (7/21 [33%], p = .47). In total, lens extraction was achieved in 19/20 (95%) ICLEs and lens reduction was achieved in 28/31 (90%) TCLRs. Anterior lens luxation recurred in 10/24 (41%) TCLRs.

CONCLUSIONS

The present study adds data to the current knowledge base regarding the treatment of ALL in dogs and highlights the need for future prospective studies containing a larger number of animals to help inform treatment decisions for dogs with ALL.

The effects of smoking on cardiac structure and function in a general population

Background

Cigarette smoking is the leading preventable cause of death worldwide. Smoking is known to cause coronary artery disease, but studies have also shown that smoking independently is associated with higher risk of heart failure. However, the link between smoking and cardiac structure and function is not yet fully examined.

Purpose

The aim of the study was to investigate the independent effect of cigarette smoking on cardiac structure and function in a general population using echocardiographic measures.

Methods

A prospective cohort of 3,874 participants from a general population free of prevalent heart disease underwent an echocardiographic examination including two-dimensional speckle-tracking analysis. Smoking history was obtained through a self-administered questionnaire, that generated three groups; current smokers (18.6%), former smokers (40.9%) and never smokers (40.5%). Pack-years were estimated from the questionnaire.

Results

After multivariable adjustment for age, sex, body mass index, hypertension, hypercholesterolemia, diabetes and lung function, current smokers had significantly alterations in septal thickness (1.1±0.2 cm, P=0.018) and relative wall thickness (0.4±0.1 cm, P=0.016) compared to never smokers. Furthermore, left ventricular mass index (LVMi) was increased in current smokers compared to never smokers (85.8±19.3 g/cm2, P=0.048). Reduced left ventricle systolic function as assessed by global longitudinal strain (GLS) was evident in current smokers compared to never smokers (19.1±2.3%, P&lt;0.001). Additionally, after multivariable adjustment increasing pack-years was associated with decreases in left ventricular ejection fraction (LVEF) (β=−0.04, P=0.031), E/A ratio (β=−0.06, P&lt;0.001) and GLS (β=−0.04, P=0.008). Comparing cardiac structure and function in never smokers, continuous smokers and former smokers after 10 years, showed that continuous smokers developed increased LVMi (Δ=3.97±17.48 g/cm2, P&lt;0.001) and decreased GLS (Δ=−0.77±3.84%, P=0.04) and LVEF (Δ=−4.23±5.7, P&lt;0.001) compared to never and former smokers.

Conclusion

In a large general population study without known heart disease, current smoking and accumulated pack-years were independently associated with alterations in cardiac structure and reduced systolic function. Furthermore, we found that continuous smokers over a 10-year period developed relatively worse systolic function and increased LV structure alterations compared to never smokers and to participants that stopped smoking during that period.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Copenhagen City Heart Study is funded by The Danish Heart Foundation andThe Metropolitan Region of Denmark.

866 A Lateral Approach Is More Likely to Be Successful Than A Posterior Approach for An Injection to Reach the Subacromial Space

Background

Subacromial injections are common for diagnosis and therapy of shoulder impingement secondary to subacromial bursitis. We evaluated the likelihood of a successful subacromial injection from both the posterior and lateral injection sites.

Method

We reviewed 100 MRI scans of the shoulder and recorded measurements in both the sagittal (representative of posterior injection) and coronal (representative of lateral injection) orientations. We compared these to the lengths of standard needles.

Multiple measurements were taken:

Results

Measuring along the angle of the acromion demonstrated shorter mean distances from the lateral injection site. The distance from skin to mid-point of the acromion) provided mean values of 51.4mm for posterior and 40.1mm for lateral. A standard 40mm (green) needle would reach the midpoint of the acromion in 58% of lateral measurements and 23% from posterior.

Conclusions

Injections are more likely to enter the subacromial space from a lateral rather than a posterior entry point.

Conjunctival staining with lissamine green as a predictor of tear film deficiency in dogs

OBJECTIVE

To evaluate a grading scheme for conjunctival staining patterns with lissamine green ocular dye in the diagnosis of tear film deficiencies in dogs.

PROCEDURES

Client-owned and research colony dogs were enrolled in a prospective study between February and October 2018 in which slit-lamp biomicroscopy, Schirmer tear test (STT), tear film breakup time (TFBUT), conjunctival lissamine green staining (LGS), and intraocular pressure (IOP) measurement were performed in both eyes of all dogs. Lissamine green staining of the temporal bulbar conjunctiva was graded from 0-3, with a higher grade corresponding to an increased stain intensity.

RESULTS

Fifty-four dogs (107 eyes), comprising 31 males and 23 females with a mean age of 5.0 ± 3.9 years (range 0.5-14.3), were enrolled in the study. STT was <15 mm/min in 21 eyes and ≥15 mm/min in 86 eyes. Lissamine green staining grade for eyes with a STT of <15 mm/min (2.0 ± 0.9) was significantly higher than for eyes with a STT ≥15 mm/min (0.2 ± 0.7) (P < .001). TFBUT for eyes with a STT <15 mm/min (6.5 ± 4.4 seconds) was significantly shorter than for eyes with a STT ≥ 15 mm/min (16.1 ± 3.6 seconds) (P < .001). As LGS grade increased, both STT (P < .001) and TFBUT (P < .001) significantly decreased.

CONCLUSIONS

A higher LGS grade was significantly associated with a lower STT and more rapid TFBUT in dogs. Lissamine green ocular dye can be considered as an adjunctive diagnostic test when evaluating tear film deficiency in dogs.

Testing Hadronic Interactions at Ultrahigh Energies with Air Showers Measured by the Pierre Auger Observatory

Ultrahigh energy cosmic ray air showers probe particle physics at energies beyond the reach of accelerators. Here we introduce a new method to test hadronic interaction models without relying on the absolute energy calibration, and apply it to events with primary energy 6-16 EeV (E_{CM}=110-170  TeV), whose longitudinal development and lateral distribution were simultaneously measured by the Pierre Auger Observatory. The average hadronic shower is 1.33±0.16 (1.61±0.21) times larger than predicted using the leading LHC-tuned models EPOS-LHC (QGSJetII-04), with a corresponding excess of muons.

Measurement of the Radiation Energy in the Radio Signal of Extensive Air Showers as a Universal Estimator of Cosmic-Ray Energy

We measure the energy emitted by extensive air showers in the form of radio emission in the frequency range from 30 to 80 MHz. Exploiting the accurate energy scale of the Pierre Auger Observatory, we obtain a radiation energy of 15.8±0.7(stat)±6.7(syst)  MeV for cosmic rays with an energy of 1 EeV arriving perpendicularly to a geomagnetic field of 0.24 G, scaling quadratically with the cosmic-ray energy. A comparison with predictions from state-of-the-art first-principles calculations shows agreement with our measurement. The radiation energy provides direct access to the calorimetric energy in the electromagnetic cascade of extensive air showers. Comparison with our result thus allows the direct calibration of any cosmic-ray radio detector against the well-established energy scale of the Pierre Auger Observatory.

Search for patterns by combining cosmic-ray energy and arrival directions at the Pierre Auger Observatory

Energy-dependent patterns in the arrival directions of cosmic rays are searched for using data of the Pierre Auger Observatory. We investigate local regions around the highest-energy cosmic rays with [Formula: see text] eV by analyzing cosmic rays with energies above [Formula: see text] eV arriving within an angular separation of approximately 15[Formula: see text]. We characterize the energy distributions inside these regions by two independent methods, one searching for angular dependence of energy-energy correlations and one searching for collimation of energy along the local system of principal axes of the energy distribution. No significant patterns are found with this analysis. The comparison of these measurements with astrophysical scenarios can therefore be used to obtain constraints on related model parameters such as strength of cosmic-ray deflection and density of point sources.

Public Health England survey of eye lens doses in the UK medical sector

The ICRP has recently recommended that the occupational exposure limit for the lens of the eye be reduced to 20 mSv in a year, averaged over defined periods of 5 years, with no single year exceeding 50 mSv. There has been concern amongst some groups of individuals, particularly interventional cardiologists and radiologists as well as relevant professional bodies, that implementation of these recommendations into UK law will adversely affect working patterns. However, despite a number of informative European studies, there is currently little UK dosimetry data available upon which judgements can effectively be based. In order to address this knowledge gap, Public Health England has carried out a small, targeted survey of UK lens doses to medical staff undertaking procedures likely to involve the highest levels of radiation exposure. Two out of a total of 61 individuals surveyed had projected annual doses which could be close to 20 mSv, measured outside lead glasses. Use of protective equipment was generally good; however, lead glasses were only used by 9 participants. The results of this survey suggest that compliance with the ICRP recommendations is likely to be possible for most individuals in the UK medical sector.

Fluoroquinolone exposure prior to tuberculosis diagnosis is associated with an increased risk of death

SETTING

Fluoroquinolone (FQ) exposure before tuberculosis (TB) diagnosis is common, but its effect on outcomes, including mortality, is unclear.

DESIGN

Among TB patients reported to the Tennessee Department of Health from 2007 to 2009, we assessed FQ exposure within 6 months before TB diagnosis. The primary outcome was the combined endpoint of death at the time of TB diagnosis and during anti-tuberculosis treatment.

RESULTS

Among 609 TB cases, 214 (35%) received FQs within 6 months before TB diagnosis. A total of 71 (12%) persons died; 10 (2%) were dead at TB diagnosis and 61 (10%) died during anti-tuberculosis treatment. In multivariable logistic regression analysis, factors independently associated with death were older age (OR 1.05 per year, 95%CI 1.04-1.07), human immunodeficiency virus infection (OR 8.08, 95%CI 3.83-17.06), US birth (OR 3.03, 95%CI 1.03-9.09), and any FQ exposure before TB diagnosis (OR 1.82, 95%CI 1.05-3.15). Persons with FQ exposure before TB diagnosis were more likely to have culture- and smear-positive disease than unexposed persons.

CONCLUSIONS

Among this patient population, FQ exposure before TB diagnosis was associated with an increased risk of death. These findings underscore the need for cautious use of FQs in persons with possible TB.

Polymyositis following Vogt-Koyanagi-Harada-like syndrome in a Jack Russell terrier

A male Jack Russell terrier developed bilateral uveitis and glaucoma at 1 year of age. Since the ocular disease was painful and unresponsive to treatment, both globes were enucleated. Microscopical evaluation of one enucleated globe revealed panuveitis, with pigment dispersion and phagocytosis consistent with the ocular lesions of canine Vogt-Koyanagi-Harada (VKH)-like syndrome. Three years later the dog was represented with severe muscle disease and skin lesions. Due to rapid clinical deterioration the dog was humanely destroyed. Necropsy examination revealed lichenoid interface inflammation in the skin and mucous membranes, with pigmentary incontinence consistent with VKH-like syndrome and lymphocytic and histiocytic polymyositis with marked muscle atrophy. Canine VKH-like syndrome is an autoimmune disease that targets melanocyte antigens. Some human patients with VKH disease develop additional autoimmune diseases. To our knowledge this is the first reported case of polymyositis subsequent to VKH-like disease in a dog. In addition, VKH-like disease has not been previously reported in a Jack Russell terrier.

Ogilvie's syndrome: a case report

OBJECTIVE

Ogilvies syndrome (OS) is a rare condition in obstetrics but occurs most commonly after caesarean section. Mortality rates from OS can be as high as 36-50% when bowel perforation or ischemia develops which highlights the early recognition of this condition. Early diagnosis is therefore essential to prevent serious morbidity and mortality.

CONCLUSION

We, therefore report a case of OS after caesarean section in which early detection by senior clinicians resulted in successful management of the condition and an excellent outcome.

The phenol red thread tear test in large Psittaciformes

OBJECTIVE

To develop a standard method for measuring tear production in large Psittaciformes using the phenol red thread (PRT) tear test. To establish mean PRT tear test values in clinically normal pet birds and to assess the reproducibility of the test.

ANIMALS

Two geographically distinct populations of healthy, large Psittaciformes (pilot study and study population). Species groups include: cockatoo (17), macaw (22), Amazon (10), African gray (1), eclectus (1) and pionus (1).

PROCEDURE

The PRT was placed under the upper eyelid and both eyelids were held closed throughout the test. The PRT tear test was repeated after 2 months in the pilot study and after approximately 5 min in the study population.

RESULTS

The mean PRT tear test values for the pilot study were OD=28.2 mm/15 s (+/- 6.3 mm), OS=24.1 mm/15 s (+/- 6.6 mm) and OD=25.4 mm/15 s (+/- 3.3 mm), OS=25.5 mm/15 s (+/- 5.2 mm), for the first and second visits respectively. The mean PRT tear test value for the study population was: OD=19.8 mm/15 s (+/- 4.3 mm), OS=20.1 (+/- 3.9 mm) and OD=20.0 mm/15 s (+/- 4.5 mm), OS=19.1 mm/15 s (+/- 3.3 mm), for the first and second tests respectively. There was poor repeatability between tests.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that the PRT tear test is a practical method for measuring tear production in large Psittaciformes, although adaptations to the established diagnostic method are necessary to overcome some anatomical differences present in birds. Good reproducibility of the PRT tear test could not be demonstrated in a clinically normal population of birds but geographic location appears to significantly influence results.

Extranodal conjunctival Hodgkin's-like lymphoma in a cat

A seven-year-old female spayed Domestic Short-haired cat was brought for examination following a four-month history of conjunctivitis in the right eye. The superior palpebral conjunctiva was diffusely swollen and firm, displacing the right globe ventrally and preventing full closure of the eyelids. The right popliteal lymph node was enlarged as were several other peripheral lymph nodes. An incisional biopsy of the conjunctival swelling revealed a lymphoid neoplasm, the cellular make up of which suggested features of feline Hodgkin's-like lymphoma. Although the neoplasm was poorly responsive to standard chemotherapeutic protocols for lymphoma, radiation therapy rapidly reduced its size. Three years following the initial diagnosis, there has been no recurrence of the conjunctival neoplasm. To the authors' knowledge, there are no previous reports of extranodal or adnexal (conjunctiva, eyelid, orbit) Hodgkin's-like lymphoma in the veterinary literature.

Ophthalmic emergencies

Ophthalmic emergencies are common presenting complaints in an emergency room. Most ophthalmic emergencies can be treated and stabilized until an ophthalmologist can be consulted. Most ocular emergencies involve loss of vision, compromised globe integrity, or severe ocular pain. Delay in treating true emergencies may result ina blind eye or loss of an eye. This article discusses the clinical signs,diagnosis, and treatment as well as the prognosis of some of the more common ophthalmic emergencies.

Inheritance, biochemical abnormalities, and clinical features of feline mucolipidosis II: the first animal model of human I-cell disease

Mucolipidosis II (ML II), also called I-cell disease, is a unique lysosomal storage disease caused by deficient activity of the enzyme N-acetylglucosamine-1-phosphotransferase, which leads to a failure to internalize enzymes into lysosomes. We report on a colony of domestic shorthair cats with ML II that was established from a half-sibling male of an affected cat. Ten male and 9 female kittens out of 89 kittens in 26 litters born to clinically normal parents were affected; this is consistent with an autosomal recessive mode of inheritance. The activities of three lysosomal enzymes from affected kittens, compared to normal adult control cats, were high in serum (11-73 times normal) but low in cultured fibroblasts (9-56% of normal range) that contained inclusion bodies (I-cells), reflecting the unique enzyme defect in ML II. Serum lysosomal enzyme activities of adult obligate carriers were intermediate between normal and affected values. Clinical features in affected kittens were observed from birth and included failure to thrive, behavioral dullness, facial dysmorphia, and ataxia. Radiographic lesions included metaphyseal flaring, radial bowing, joint laxity, and vertebral fusion. In contrast to human ML II, diffuse retinal degeneration leading to blindness by 4 months of age was seen in affected kittens. All clinical signs were progressive and euthanasia or death invariably occurred within the first few days to 7 months of life, often due to upper respiratory disease or cardiac failure. The clinical and radiographic features, lysosomal enzyme activities, and mode of inheritance are homologous with ML II in humans. Feline ML II is currently the only animal model in which to study the pathogenesis of and therapeutic interventions for this unique storage disease.

Scaling exponent predicts defibrillation success for out-of-hospital ventricular fibrillation cardiac arrest

BACKGROUND

-Defibrillator shocks often fail to terminate ventricular fibrillation (VF) in out-of-hospital cardiac arrest (OOHCA), and repeated failed shocks can worsen the subsequent response to therapy. Because the VF waveform changes with increasing duration of VF, it is possible that ECG analyses could estimate the preshock likelihood of defibrillation success. This study examined whether an amplitude-independent measure of preshock VF waveform morphology predicts outcome after defibrillation. Methods and Results-Clinical data and ECG recordings from an automated external defibrillator were obtained for 75 subjects with OOHCA in a suburban community with police first responders and a paramedic-based emergency medical system. An estimate of the fractal self-similarity dimension, the scaling exponent, was calculated off-line for the VF waveform preceding shocks. Success of the first shock was determined from the recordings. Return of pulses and survival were determined by chart review. The first shock resulted in an organized rhythm in 43% of cases, and 17% of cases survived to hospital discharge. A lower mean value of the scaling exponent was observed for cases in which the first defibrillation resulted in an organized rhythm (P:=0.004), for cases with return of pulses (P:=0.049), and for cases surviving to hospital discharge (P:<0.001). Receiver operator curves revealed the utility of the scaling exponent for predicting the probability of restoring an organized rhythm (area under the curve=0.70) and of survival (area under the curve=0.84).

CONCLUSIONS

-The VF waveform in OOHCA can be quantified with the scaling exponent, which predicts the probability of first-shock defibrillation and survival to hospital discharge.

Altered E-C coupling in rat ventricular myocytes from failing hearts 6 wk after MI

Excitation-contraction (E-C) coupling was investigated in rat hearts 6 wk after induction of myocardial infarction (MI) by ligation of the left coronary artery. Heart weight was increased by 74% and left ventricular end-diastolic pressure was 23 +/- 2 mmHg in MI compared with 8 +/- 2 mmHg in sham-operated controls (Sham, P < 0.001). Cell shortening was measured in voltage-clamped myocytes at 36 degrees C. In solutions where Cs(+) had been replaced by K(+), the voltage dependence of contraction was sigmoidal between -20 and +100 mV in Sham and MI cells. Verapamil (20 microM) blocked L-type Ca(2+) current and reduced contraction in Sham cells by approximately 50% (P < 0.01) but did not decrease contraction significantly in MI cells at test potentials above +10 mV. Verapamil-insensitive contractions were blocked by Ni(2+) (5 mM). Na(+)/Ca(2+) exchange current was doubled in MI compared with Sham cells at test potentials between -20 and +80 mV (P < 0.05), whereas mRNA and protein expression increased by 30-40%. Finally, voltage dependence of contraction was bell shaped in Na(+)-free solutions, but contraction was significantly increased in MI cells over a wider voltage range (P < 0.05). The insensitivity to Ca(2+) channel block in MI cells may result from an increased contribution of the Na(+)/Ca(+) exchanger to triggering of E-C coupling. These results suggest significant changes in E-C coupling in the hypertrophy and failure that develop in response to extensive MI.

The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland

OBJECTIVE

To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children.

DESIGN

Randomized controlled trial.

SETTING

Six AFDC jurisdictions in Maryland.

INTERVENTION

Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not.

PARTICIPANTS

Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups).

MAIN OUTCOME MEASURES

Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year.

ANALYSIS

Comparisons among baseline and postimplementation years 1 and 2.

RESULTS

Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status.

CONCLUSIONS

The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

Thyroid hormone control of contraction and the Ca(2+)-ATPase/phospholamban complex in adult rat ventricular myocytes

Thyroid hormones may have important long-term effects on cellular Ca2+ handling in the heart. We investigated isolated adult rat cardiomyocytes in a primary culture exposed (T3-cells) or not exposed to (control cells) 10(-8) M triiodothyronine (T3) for 48 h. Northern blot analysis revealed reciprocal alterations in the expression of SERCA2 and phospholamban. The ratio of the SERCA2/phospholamban signal was approximately 10 times higher in the T3-cells as compared with the control cells (P < 0.05). Phospholamban protein content was significantly reduced by 33% but SR-Ca(2+)-ATPase protein content was not significantly altered in T3-cells. These results were associated with functional alterations measured by an inverted microscope equipped to monitor fluorescence at two excitation wavelengths as well as cell shortening by a video edge detection unit. The peak calcium transients as measured by fura-2 acetoxymethyl ester (AM) were increased significantly during stimulation at 0.25 and 0.5 Hz in T3-cells compared with control cells (P < 0.05). The monoexponential decline of the fura-2 transient was significantly faster at all frequencies in the T3-cells as compared with control cells (P < 0.05). Interestingly, we observed blunted responses to both isoproterenol stimulation and post rest potentiation in the T3-cells. The intracellular level of sodium as represented by SBFI-AM was significantly lower in the T3-cells compared with the control cells (P < 0.05). The increased SR-Ca(2+)-ATPase/phospholamban ratio and decrease in phospholamban protein content in T3-treated cells was reflected in a parallel increase of contraction and calcium transients and more rapid Ca2+ reuptake, but the post-rest potentiation and response to isoproterenol were reduced.

The relation of parent and provider characteristics to vaccination status of children in private practices and managed care organizations in Maryland

OBJECTIVES

This study sought to identify provider practices and policies in private pediatric settings that relate to vaccination status, controlling for the characteristics of the children served.

METHODS

Vaccination data came from the medical records of 709 randomly selected 2-year-old children at 18 private practices and managed care organizations in Maryland, family data from 466 telephone interviews with the children's parents, and provider characteristics from 18 site questionnaires and 42 individual physician and nurse practitioner questionnaires. Logistic regression and generalized estimating equations were used to estimate the relation of provider characteristics to vaccination status. Three age-appropriate (AA) and two up-to-date (UTD) vaccination status variables characterized successful vaccination.

RESULTS

Approximately 70% of the study children were up-to-date by age 2 years for the full vaccination series, excluding hepatitis B vaccine. Family demographic characteristics were the strongest correlates of undervaccination. Neither parents' knowledge and attitudes about immunization nor the children's insurance coverage was statistically related to vaccination status. Site reminder or follow-up systems and provider perceptions about appointment scheduling and receipt of vaccine information from health departments were positively related to vaccination. Concern for liability was associated with a reduced odds of age-appropriate and up-to-date vaccination.

CONCLUSIONS

Family demographics strongly correlate with vaccination status; however, they are generally not modifiable. This study's findings encourage providers to operate a tracking system, to remain current on immunization recommendations, to use all clinical encounters to screen and vaccinate children, and to ensure the availability and convenience of vaccination services.

Mechanisms of cardiomyocyte dysfunction in heart failure following myocardial infarction in rats

Available information regarding the cellular and molecular mechanisms for reduced myocardial function after myocardial infarction (MI) is scarce. In rats with congestive heart failure (CHF), we examined cardiomyocytes isolated from the non-infarcted region of the left ventricle 6 weeks after ligation of the left coronary artery. Systolic left-ventricular pressure was reduced and diastolic pressure was markedly increased in the CHF-rats. The cardiomyocytes isolated from the CHF-hearts had increased resting length, reduced fractional shortening by 31% and a 34% increase in time to 90% relaxation compared to sham cells (P<0.01 for all). Peak L-type calcium currents were not significantly changed, but peak calcium transients measured with fura-2 were reduced by 19% (P<0.01). Moreover, the decline of the calcium transients as measured by the time constant of a monoexponential function was significantly increased by 26% (P<0.01). We also examined the contribution of the Ca2+-ATPase of the sarcoplasmic reticulum (SR) in the removal of cytosolic Ca2+ during relaxation by superfusing cells with 1 microM thapsigargin that effectively inhibits the Ca2+-ATPase. Relaxation time in CHF-cells was significantly less prolonged when this drug was used (P<0.01). This suggests that other mechanisms, probably the Na+-Ca2+ exchanger, contribute significantly to the relaxation rate in CHF. Simultaneous measurements of fura-2 transients and mechanical shortening did not reveal any alteration in the calcium-myofilament sensitivity in CHF. Our study clearly shows reduced shortening and prolonged relaxation in cardiomyocytes isolated from non-infarcted region of the left ventricle in heart failure. Moreover, we were able to relate the observed cardiomyocyte dysfunction to changes in specific steps in the excitation-contraction coupling.

Reduced myocardial Na+, K(+)-pump capacity in congestive heart failure following myocardial infarction in rats

We examined changes in expression and function of the cardiac Na+, K(+)-pump in a post-infarction rat model of hypertrophy and congestive heart failure (CHF). Myocardial infarction was induced by ligation of the left coronary artery in Wistar rats and hearts were obtained from animals with CHF and from sham operated rats after 6 weeks. In the CHF group the ratio of heart weight to body weight was 70% greater compared to sham (*P < 0.05) and all left-ventricular end-diastolic pressures (LVEDP) were above 15 mmHg. The expression of the alpha 1- and beta 1-subunits (mRNA and protein) of the Na+, K(+)-pump was not significantly different in CHF and sham. As compared to sham the alpha 2 isoform, mRNA and protein levels were lower in CHF hearts by 25 and 55%, respectively, whereas the alpha 3 isoform mRNA was greater by 120% in CHF. The alpha 3 protein was not detectable in sham but a prominent band was seen in CHF. Cell volume of isolated cardiomyocytes was 30% larger in CHF. Cardiomyocytes containing the Na+ sensitive fluorescent dye SBFI were loaded to an intracellular Na+ concentration ([Na+]i] of about 140 mM in a K(+)- and Mg(2+)-free medium (140 mM Na+, free Ca2+ of 10(-8) M). To avoid back leak of Na+ and to ensure no voltage effects on the Na+, K(+)-pump extracellular Na+ was subsequently removed, and 6 mM Mg2+ was added to the superfusate, The Na+, K(+)-pump was then reactivated by 10 mM Rb+. SBFI fluorescence ratio decreased mono-exponentially with a time constant (tau) of 191 +/- 15 s in sham (n = 8) and 320 +/- 38 s in CHF (n = 9) rats (P < 0.01). These changes in fluorescence indicate that the maximum rate of decline of [Na+]i from 100 to 35 mM was 39% (P < 0.005) slower in CHF compared to sham, whereas maximum pump rate per cell was not significantly altered (9.0 +/- 0.7 fmol/s in sham and 7.1 +/- 0.7 fmol/s in CHF cells). The [Na+]i which caused 50% pump activation (k0.5) was also not altered in CHF (40 mM in both groups). We conclude that the number of Na+, K(+)-pumps per cell was maintained in CHF but an isoform switch of the alpha 3-replacing the alpha 2-isoform occurred. However, maximum Na+, K(+)-pump rate in terms of rate of change of [Na+]i was significantly attenuated in CHF, most likely as a result of increased cell size.

Initiating the first DTP vaccination age-appropriately: a model for understanding vaccination coverage

OBJECTIVE

Our earlier research found that the strongest predictor of not being up to date on the full series of immunizations by 24 months is failure to receive the first diphtheria vaccine and tetanus toxoid and pertussis vaccine (DTP1) on time. To learn more about the relationship between successful vaccination during the DTP1 age-appropriate (DTP1-AA) period (between 42 and 92 days of life, inclusive) and an infant's early visit to the physician (before 42 days of life), we quantified children's progression through a sequence of provider visits and outcomes.

DESIGN

This study analyzed data from 426 children living in the 57 poorest census tracts in Baltimore. For each DTP1-AA visit, we calculated the percentage of times a DTP1-AA vaccination, provider missed opportunity, or deferral for a valid contraindication occurred. Relative and attributable risks were computed to assess associations between DTP1-AA vaccination and early visits and missed opportunities.

RESULTS

We found the following: 1) Children who made a visit before 42 days of life were more than twice as likely to receive a DTP1-AA vaccination; 2) the missed opportunity rate for children who did not make an early visit was approximately twice that of the early-visit group; and 3) well visits were more likely to result in DTP1-AA immunization than sick visits. Attributable risk calculations show that DTP1-AA vaccination rates could be increased in this population by one third if all infants had an early visit.

CONCLUSIONS

Early in-office visits seem to make DTP1-AA vaccination more likely. These rates may be amenable to intervention by increasing early visits and reducing DTP1-AA missed opportunities. Introduction of the hepatitis B vaccine to the recommended series may place more emphasis on early visits and result in increased DTP1-AA rates and, ultimately, higher vaccination coverage rates.

Opiate disruption of maternal behavior: morphine reduces, and naloxone restores, c-fos activity in the medial preoptic area of lactating rats

Morphine significantly impairs maternal behavior; naloxone, an opiate antagonist, restores it. Maternal behavior is associated with c-fos expression, an immediate early gene product, in the medial preoptic area (mPOA) of females. In two experiments, the effects of morphine-alone and morphine plus naloxone on the expression of c-fos were examined. On postpartum day 5, females were injected with morphine or saline (experiment 1), and morphine + naloxone or morphine + saline (experiment 2) and placed back in the home-cage, separated from their pups by a wire-mesh partition. A separate group in experiment 1 was injected but not exposed to pups. Processing for c-fos immunohistochemistry commenced, and c-fos positive cells in a proscribed portion of mPOA were counted. Morphine-treated females had fewer c-fos cells in mPOA compared to saline-treated females, and the presence of pups accounted for a significant increase in c-fos-expressing neurons, whereas in females not exposed to pups, morphine treatment did not significantly reduce baseline c-fos expression (experiment 1). Furthermore, naloxone mitigated the effect as morphine + naloxone-treated females expressed more c-fos cells compared to morphine + saline females (experiment 2). Morphine-treated females, therefore, may exhibit reductions in maternal behavior because of relative opiate-induced inactivation of areas of the brain devoted to the regulation of maternal behavior.

Effectiveness of pediatric practice consultation on missed opportunities for immunization

OBJECTIVE

To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines.

DESIGN

The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed.

RESULTS

The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions.

CONCLUSIONS

There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities.

Estimating vaccination coverage using parental recall, vaccination cards, and medical records

OBJECTIVE

To compare estimates based on vaccination cards, parental recall, and medical records of the percentages of children up-to-date on vaccinations for diphtheria, tetanus, and pertussis; polio; and measles, mumps, and rubella.

METHOD

The authors analyzed parent interview and medical records data from the Baltimore Immunization Study for 525 2-year-olds born from August 1988 through March 1989 to mothers living in low-income Census tracts of the city of Baltimore.

RESULTS

Only one-third of children had vaccination cards; based on medical records, these children had higher up-to-date coverage at 24 months of age than did children without cards. For individual vaccines, only two-thirds of parents could provide information to calculate coverage rates; however, almost all provided enough information to estimate coverage for the primary series. For each vaccine and the series, parental recall estimates were at least 17 percentage points higher than estimates from medical records. For children without vaccination cards whose parents could not provide coverage information, up-to-date rates based on medical records were consistently lower than for children with cards or with parents who provided coverage information.

CONCLUSIONS

Population-based vaccine coverage surveys that rely on vaccination cards or parental recall or both may overestimate vaccination coverage.

Deficiencies in current childhood immunization indicators

OBJECTIVE

To investigate "up-to-date" and "age-appropriate" indicators of preschool vaccination status and their implications for vaccination policy.

METHODS

The authors analyzed medical records data from the Baltimore Immunization Study for 525 2-year-olds born from August 1988 through March 1989 to mothers living in low-income Census tracts of the city of Baltimore.

RESULTS

While only 54% of 24-month-old children were up-to-date for the primary series, indicators of up-to-date coverage were consistently higher, by 37 or more percentage points, than corresponding age-appropriate indicators. Almost 80% of children who failed to receive the first dose of DTP or OPV age-appropriately failed to be up-to-date by 24 months of age for the primary series.

CONCLUSIONS

Age-appropriate immunization indicators more accurately reflect adequacy of protection for preschoolers than up-to-date indicators at both the individual and population levels. Age-appropriate receipt of the first dose of DTP should be monitored to identify children likely to be underimmunized. Age-appropriate indicators should also be incorporated as vaccination coverage estimators in population-based surveys and as quality of care indicators for managed care organizations. These changes would require accurate dates for each vaccination and support the need to develop population-based registries.

Electrical stimulation of adult rat cardiomyocytes in culture improves contractile properties and is associated with altered calcium handling

A major limitation in long-term studies of quiescent adult cadiomyocytes in culture has been the decline in contractile properties of the cells over time. Regular contracting cardiomyocyte cultures may represent a more physiological model. The aim of the present study was to investigate the mechanical properties and calcium handling of myocytes after 24 hours of electrical stimulation at 1 Hz. In a random and blind design, stimulated (S) and unstimulated (U) myocytes were examined using an inverted microscope which allows continuous length recordings and measurements of intracellular Ca2+. Fractional shortening examined at 0.25 Hz was 14.67 +/- 0.51% in S cells and was not significantly different from U cells. However, at higher frequencies we found a significant difference in mechanical properties between the two groups. At 2 Hz fractional shortening was 12.03 +/- 0.67% in S cells, but only 8.07 +/- 0.94% U cells (P < 0.05). We were able to abolish the difference between the two groups by stimulating with the beta-adrenergic agonist isoproterenol. Measurements of Ca2+ transients were made at 1 Hz after loading with fura 2-AM. Peak fura 2 ratio was 25.4% greater in S cell compared to U cells. Resting fura ratios were not significantly different. Caffeine-induced transients were greater in S than in U cells. [3H]-ryanodine-binding and Ca(2+)-ATPase contents were not significantly different. In conclusion, we have found that regular electrical stimulation of adult ventricular myocytes in culture, so that they contract rhythmically, enhances both mechanical properties and calcium transients when compared to quiescent myocytes. These results suggest that regular electrical stimulation is important when studying the function of adult ventricular myocytes in culture.

Transient Ca2+ overload alters Ca2+ handling in rat cardiomyocytes: effects on shortening and relaxation

Transient Ca2+ overload in cardiomyocytes occurs during pathophysiological conditions. The aim of the present study was to investigate the effects of transient Ca2+ overload on shortening and relaxation in isolated rat cardiomyocytes electrically stimulated at 0.5 Hz and to examine whether transient Ca2+ overload induces alterations in Ca2+ handling and myofilament sensitivity. Fractional shortening and shortening velocity fell to 79 +/- 5% (P < 0.05) and 78 +/- 4% (P < 0.01) 2 min after exposure to high Ca2+. A transient decrease in resting length, a reduction in relaxation velocity to 86 +/- 7% (P < 0.05), and a prolonged time of relaxation with 8.3 +/- 4.3% (P < 0.05) were also observed. Systolic fluorescence ratio using fura 2 as the Ca2+ indicator fell by 11.0%, and the decline of the fluorescence ratio was prolonged by 29.8%. By applying caffeine, we observed a significant reduction in sarcoplasmic reticulum Ca2+ content after transient Ca2+ overload. A significant reduction in myofilament sensitivity was also observed. In conclusion, the systolic dysfunction observed after transient Ca2+ overload is the result of both decreased systolic Ca2+ and reduced myofilament sensitivity. The relaxation abnormalities are most likely caused by altered Ca2+ handling, since we observed a reduction in the sarcoplasmic reticulum Ca2+ content and a prolongation of the decline of the fura 2 transient.

Are immunizations an incentive for well-child visits?

OBJECTIVE

To assess the beliefs of parents and the visit patterns of their children to determine whether immunizations act as an incentive to use well-child care.

DESIGN AND METHODS

Medical record audits provided data on immunizations and well-child visits. Two questions from a parent interview were used to identify 4 groups of parents: (1) motivated and (2) unmotivated to keep a well-child care appointment regardless of whether immunizations are scheduled, (3) vaccine-motivated and (4) checkup-motivated (parents who were influenced negatively by the prospect of receiving vaccinations). The percentage of children with a visit at each age window for well-child visits and the percentage up-to-date for their immunizations at given ages were compared across the 4 groups. The 4 groups were also compared for other parental attitudes about immunizations and well-child visits, and on sociodemographic and access characteristics.

RESULTS

Most (73.3%) of the 502 parents surveyed were classified as motivated and 5% as unmotivated to keep a well-child care appointment regardless of whether an immunization was scheduled. Only 18.3% were categorized as vaccine-motivated and 3.4% as checkup-motivated. For all 4 groups, there was no discernible difference in attendance between immunization and nonimmunization visits. Attendance in the windows for well-child visits and percentage of children up-to-date on immunizations declined with increasing age.

CONCLUSIONS

In this inner-city population, attendance patterns at visits did not support the incentive hypothesis. This finding should reassure clinicians that providing immunizations outside of regular well-child care visits will not necessarily decrease attendance at visits for well-child care.

Increased cardiac expression of endothelin-1 mRNA in ischemic heart failure in rats

OBJECTIVES

Plasma endothelin (ET) concentrations are increased in heart failure. The aims of the present study were to investigate to what extent cardiac ET mRNA expression is induced in ischemic heart failure and whether there may be compensatory downregulation of myocardial mRNA levels for the ETA and ETB receptor subtypes.

METHODS

In rats with ischemic heart failure (left ventricular end-diastolic pressure > 15 mmHg) due to left coronary artery ligation. Northern blot analyses were performed on mRNA isolated from cardiac tissues.

RESULTS

A substantial upregulation was revealed in all chambers of the failing hearts. Up to 27-fold upregulation (mean 10.6 +/- 4.0, P = 0.002) of left ventricular ET-1 mRNA levels was measured 1 week after myocardial infarction, whereas only a modest upregulation was detected after 6 weeks (mean 2.7 +/- 0.5, P < 0.05). Ribonuclease protection assay revealed 2.8 +/- 0.4-fold higher levels of ET-1 mRNA in the left ventricular area subjected to myocardial infarction compared to the non-infarcted tissue after 1 week. Left ventricular ET-1 mRNA correlated significantly with left ventricular end-diastolic pressure after 1 week (r2 = 0.86, P = 0.007). The ETA and ETB receptor mRNA levels tended to increase 1 week after myocardial infarction although these changes were not statistically significant.

CONCLUSIONS

Cardiac ET-1 mRNA levels are increased in ischemic heart failure and correlate significantly with left ventricular end-diastolic pressure 1 week after myocardial infarction. The increase in cardiac ET-1 mRNA is not accompanied by a decrease in ET receptor mRNA.

Parental attitudes do not explain underimmunization

OBJECTIVE

This article describes the results of a community-based study to determine the effect of family knowledge and attitudes on the immunization rates of a random sample of children younger than 2 years in the poorest census tracts of Baltimore.

DESIGN AND METHODS

The two sources of data were (1) parent interviews that provided data on knowledge, attitudes, and beliefs related to immunization and sociodemographic characteristics, and (2) medical record audits from which data on immunization status were obtained. The protection motivation theory, a model of behavioral change, was used to select the variables to assess the relation of parental attitudes with immunization status. A multivariate logistic regression analysis included only variables found to be significantly associated with immunization outcome in the preliminary analysis.

RESULTS

Mothers were well informed and generally had favorable attitudes toward immunizations. Immunization status was more strongly associated with the sociodemographic characteristics of the children than with the protection motivation theory variables. Only two protection motivation theory variables were associated with more than one immunization outcome. The children of mothers who perceived that timing of vaccination did not matter were less likely to be immunized than children of care takers who thought that it did matter and children whose parents believed in the safety of multiple immunizations were less likely to be immunized than children whose parents did not hold this belief.

CONCLUSIONS

In this study, parents' attitudes and beliefs had little effect on their children's immunization levels. Interventions intended to heighten parental awareness about immunization may have little impact. In poor urban neighborhoods, African-American children whose mothers are young, have multiple siblings, and do not use the Women, Infants and Children program may be at highest risk for delayed immunization.

Randomized, placebo-controlled, double blinded trial of dexamethasone in African children with sepsis

OBJECTIVE

To determine the effect of moderate dose dexamethasone administered before antibiotics on the outcome of African children with sepsis.

METHODS

The design was a randomized, double blinded, placebo-controlled trial of dexamethasone (0.2 mg/kg) vs. placebo given intravenously before antibiotic therapy. Patients were recruited from the patient populations at two missionary hospitals. Primary outcome variables were determined before analysis of data.

RESULTS

Seventy-two children with sepsis were enrolled in the study. Treatment with dexamethasone was not associated with improved outcome for any of six outcome variables: survival to discharge (83%, dexamethasone group; 89%, placebo group); hemodynamic stability at 48 h (33%, dexamethasone group; 49%, placebo group); median length of hospital stay (11 days, dexamethasone group; 11 days, placebo group); normal at discharge (90%, dexamethasone group; 75%, placebo group); normal at follow-up (90%, dexamethasone group; 72%, placebo group); and afebrile at 48 to 72 h (61%, dexamethasone group; 44%, placebo group).

CONCLUSIONS

These data indicate that a moderate dose of dexamethasone given before antibiotic therapy did not improve outcome in the pediatric patients with sepsis whom we studied.

The contribution of missed opportunities to childhood underimmunization in Baltimore

OBJECTIVE

To determine the community-wide incidence of missed opportunities to vaccinate, to describe the clinical settings in which they occur, and to estimate the impact of missed opportunities on immunization coverage.

DESIGN AND METHODS

We abstracted outpatient medical records from a random, community-based sample of 2-year-old children whose residence was inner-city Baltimore. The date of each vaccine and the date, diagnoses, and temperature at each visit were collected for 502 children at 98 different provider sites.

MAIN OUTCOME MEASURES

Missed opportunities to vaccinate and up-to-date vaccination status.

RESULTS

By 24 months of age, 75% of the children had at least one missed opportunity and only 55% were up-to-date for the 4:3:1 series. Missed opportunities occurred at more than one third of eligible visits for each vaccine, including > 20% of preventative care visits. Diagnoses commonly associated with missed opportunities were "well child," otitis media, upper respiratory infection, gastroenteritis, skin infection, and resolving illness. If no missed opportunities had occurred, 73% of the children would have been up-to-date by 24 months.

CONCLUSIONS

Missed opportunities occurred commonly at providers serving inner-city children in Baltimore and represent a major factor in underimmunization. Reduction of missed opportunities by accurate screening at all visits and adherence to the contraindication guidelines is a provider-based, low-cost method to increase immunization coverage.

Defining the roles of parathyroid hormone-related protein in normal physiology

Parathyroid hormone-related protein (PTHrP) was discovered as a result of a search for the circulating factor secreted by cancers which causes the common paraneoplastic syndrome humoral hypercalcemia of malignancy. Since the identification of the peptide in 1982 and the cloning of the cDNA in 1987, it has become clear that PTHrP is a prohormone that is posttranslationally cleaved by prohormone convertases to yield a complex family of peptides, each of which is believed to have its own receptor. It is also clear that the PTHrP gene is expressed not only in cancers but also in the vast majority of normal tissues during adult and/or fetal life. In contrast to the situation in humoral hypercalcemia of malignancy in which PTHrP plays the role of a classical "endocrine" hormone, under normal circumstances PTHrP plays predominantly paracrine and/or autocrine roles. These apparent physiological functions are also complex and appear to include 1) regulation of smooth muscle (vascular, intestinal, uterine, bladder) tone, 2) regulation of transepithelial (renal, placental, oviduct, mammary gland) calcium transport, and 3) regulation of tissue and organ development, differentiation, and proliferation. In this review, the discovery of PTHrP, the structure of its gene and its cDNAs, and the posttranslational processing of the initial translation products are briefly reviewed. Attention is then focused on a detailed organ system-oriented review of the normal physiological functions of PTHrP.

Do provider practices conform to the new pediatric immunization standards?

OBJECTIVE

Standards for pediatric immunization practices were issued by the Centers for Disease Control and Prevention, Atlanta, Ga, in May 1992. This article provides baseline data on immunization practices related to eight of the standards.

DESIGN

Survey of pediatric providers before publication of the standards.

SETTING

Baltimore, Md.

PARTICIPANTS

Forty of the 41 health centers, clinics, and private practices serving children in designated high-risk census tracts participated in the survey. One hundred seventy-three of the 251 eligible physicians and nurse practitioners at the sites responded.

MAIN OUTCOME MEASURES

Conformity with the eight standards was measured as a percentage of either sites or physicians and nurse practitioners across the sites.

RESULTS

Conformity with the standards varied, ranging from nearly universal conformity with the need to educate parents and guardians about immunizations (standard 5) to less than 3% for simultaneous administration of all vaccine doses when a child is first eligible (standard 8). For most of the standards, considerable variability was found between and within public and private sites.

CONCLUSIONS

Providers often followed practices that did not conform to the new standards (prior to issuance). Some of the standards are ambiguous and require clarification before they can be fully applied. The impact of the standards on immunization rates and pediatric primary health care has yet to be tested empirically.

Immunization coverage and its relationship to preventive health care visits among inner-city children in Baltimore

OBJECTIVE

To provide empirical data on immunization coverage and the receipt of preventive health care to inform policy makers' efforts to improve childhood immunization.

DESIGN AND METHODS

We surveyed a random sample drawn from a birth cohort of 557 2-year-old children living in the inner-city of Baltimore. Complete information on all their preventive health care visits and immunization status was obtained from medical record audits of their health care providers.

MAIN OUTCOME MEASURES

Age-appropriate immunizations and preventive health care visits.

RESULTS

By 3 months of age, nearly 80% made an age-appropriate preventive health visit, but by 7 months of age, less than 40% had a preventive visit that was age-appropriate. In the second year of life, 75% made a preventive health visit between their 12- and 17-month birthdays. The corresponding age-appropriate immunization levels were 71% for DTP1, 39% for DTP3, and 53% for measles-mumps-rubella vaccine. Infants who received their DTP1 on-time were twice as likely to be up-to-date by 24 months of age.

CONCLUSIONS

Our analyses focus attention on the performance of the primary health care system, especially during the first 6 months of life. Many young infants are underimmunized despite having age-appropriate preventive visits, health insurance coverage through Medicaid, and providers who receive free vaccine from public agencies. Measles vaccination coverage could be improved by initiating measles-mumps-rubella vaccine vaccination, routinely, at 12 months among high risk populations.

Maternal IgG1 and IgA antibody to V3 loop consensus sequence and maternal-infant HIV-1 transmission

Maternal-infant transmission of HIV-1 occurs in 13-40% of pregnancies. Studies on transmission of maternal immunity to HIV antigens have used antigens from viruses not representative of clinical isolates and have been conflicting. Using a consensus peptide sequence based on HIV isolates found in Haiti, we found that Haitian mothers who transmitted infection to their offspring had significantly higher mean concentrations of IgG1 antibodies to the V3 loop of the primary neutralising domain of the viral envelope (gp 160) than non-transmitters (p = 0.02). Concentrations of IgA antibody to this domain were similar in transmitters and non-transmitters.

Social and psychological costs of preventive child health services in Haiti

Much of the research on determinants of health service utilization has focused on economic and cognitive variables which influence preventative health behavior. Our ethnographic study of maternal perceptions of the barriers and incentives to immunization use in Haiti underscores the importance of 'hidden' social and psychological costs of utilization, such as embarrassment, fear, child care difficulties, and competing demands on maternal time. Findings from focus group interviews with mothers, individual interviews with health care providers, and observation at health posts identified five categories of maternal factors (competing priorities, low motivation, socioeconomic constraints, fears about health or social consequences, knowledge and folk beliefs) and five categories of system factors (accessibility, acceptability, availability, accommodation, affordability) which can deter immunization completion. The discussion focuses on how these factors influence maternal decision-making regarding use of preventive child health services. More attention is needed on the psychosocial costs of health behavior in developing country settings.