Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study

OBJECTIVE

Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM.

METHODS

With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data.

RESULTS

Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small "tweaks" (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman's partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame.

CONCLUSION

Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women's views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation.

An Evaluation of Post-Concussion Return to School Guidelines: A Survey of Massachusetts School Nurses

Although all states have legislation pertaining to youth sports concussion, most of these laws focus on return-to-play procedures; only a few address return-to-learn (RTL) accommodations for students who have experienced a concussion. To address this gap in the legislation, some states and nongovernmental organizations have developed RTL guidelines to advise school personnel, parents, and health care providers on best practices for accommodating students' postconcussion reintegration into academic activity. In 2018, the Massachusetts Department of Public Health (MDPH) developed RTL guidelines which were disseminated to school nurses (SNs) at all public and nonpublic middle and high schools in the state. In 2020, the MDPH engaged the Injury Prevention Center at Boston Medical Center to survey Massachusetts SNs to assess the usefulness of the guidelines. The response rate was 63%; 92% found the booklet extremely useful or moderately useful; and 70% endorsed that the booklet fostered collaboration among stakeholders.

Clinical features and natural history of RASopathy-associated hypertrophic cardiomyopathy in children

Background

The RASopathies are a group of genetic disorders caused by germline mutations in genes encoding components of the RAS/MAPK signalling pathway and frequently associated with hypertrophic cardiomyopathy (HCM). The clinical features and outcomes of RASopathy-related HCM are incompletely understood and most published studies are limited by relatively small numbers and incomplete clinical characterisation.

Purpose

To describe the clinical features outcomes in a large, single-centre cohort of patients with RASopathy-associated HCM diagnosed <18 years.

Methods

Data from 105 patients [68 (64.8%) males] diagnosed in childhood with RASopathy-associated HCM at a single specialist centre between 1985 and 2020 were retrospectively analysed.

Results

The RASopathy diagnosis was Noonan syndrome in 69 patients (65.7%); NSML in 10 (9.5%); CFC in 6 (5.7%); Costello in 5 (4.8%) and 15 patients (14.2%) had another Noonan-like variant. 72 patients (68.6%) had a pathogenic/likely pathogenic variant in a RAS-MAPK gene, most commonly PTPN11 [n=25 (34.7%)], followed by RAF 1 [n=13 (18.1%)]. 100 patients (95.2%) were probands, 9 (8.6%) had family history of cardiomyopathy and 2 (1.9%) family history of sudden cardiac death (SCD). 52 (49.5%) had concomitant congenital heart defects (CHD) [ASD 13 (25%), VSD 6 (11.5%), PDA 1 (1.9%), >1 CHD 32 (61.5%)]. 29 (27.6%) had symptoms at baseline assessment and 56 (53.3%) were on cardiac medication. The distribution of left ventricular hypertrophy (LVH) was concentric in 47 (44.7%); 32 (30.5%) had asymmetric septal hypertrophy (ASH), and undocumented in 25 patients (23.8%). 45 patients (42.9%) had biventricular hypertrophy (BVH). Resting left ventricular outflow tract obstruction (LVOTO) was present in 39 (37.1%) with haemodynamically significant LVOTO (≥50mmHg) in 23 (21.9%). Resting right ventricular outflow tract obstruction (RVOTO) was present in 21 (20%). Over a median follow up time of 6 years, 19 patients (18.1%) died [1 (5.3%) SCD; 2 (10.5%) due to Heart Failure-related death; 1 (5.3%) due to another CVS cause; 5 (26.3%) due to a non-CVS cause and for 10 (52.6%) cause of death was unknown]. Incidence rate of death was calculated at 2.7 deaths per 100 person-years. Surgical septal myectomy was performed in 9 patients (8.6%) and 3 (2.9%) underwent cardiac transplantation. 14 patients (13.3%) suffered arrhythmic events [atrial tachycardia 6 (42.9%), Non-Sustained Ventricular Tachycardia 4 (3.8%), and Ventricular Tachycardia/Ventricular Fibrillation 4 (3.8%)].

Conclusion

To our knowledge, this is the largest cohort of RASopathy-associated HCM. The findings show a heterogeneous clinical presentation with a high prevalence of morbidity and mortality. Further work is needed to determine predictors of outcome in this population.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Onassis Foundation

SARS-CoV-2 neutralising antibodies in dogs and cats in the United Kingdom

Companion animals are susceptible to SARS-CoV-2 infection and sporadic cases of pet infections have occurred in the United Kingdom. Here we present the first large-scale serological survey of SARS-CoV-2 neutralising antibodies in dogs and cats in the UK. Results are reported for 688 sera (454 canine, 234 feline) collected by a large veterinary diagnostic laboratory for routine haematology during three time periods; pre-COVID-19 (January 2020), during the first wave of UK human infections (April–May 2020) and during the second wave of UK human infections (September 2020–February 2021). Both pre-COVID-19 sera and those from the first wave tested negative. However, in sera collected during the second wave, 1.4% (n ​= ​4) of dogs and 2.2% (n ​= ​2) of cats tested positive for neutralising antibodies. The low numbers of animals testing positive suggests pet animals are unlikely to be a major reservoir for human infection in the UK. However, continued surveillance of in-contact susceptible animals should be performed as part of ongoing population health surveillance initiatives.

A randomised controlled trial to reduce highest priority critically important antimicrobial prescription in companion animals

Robust evidence supporting strategies for companion animal antimicrobial stewardship is limited, despite frequent prescription of highest priority critically important antimicrobials (HPCIA). Here we describe a randomised controlled trial where electronic prescription data were utilised (August 2018-January 2019) to identify above average HPCIA-prescribing practices (n = 60), which were randomly assigned into a control group (CG) and two intervention groups. In March 2019, the light intervention group (LIG) and heavy intervention group (HIG) were notified of their above average status, and were provided with educational material (LIG, HIG), in-depth benchmarking (HIG), and follow-up meetings (HIG). Following notification, follow-up monitoring lasted for eight months (April-November 2019; post-intervention period) for all intervention groups, though HIG practices were able to access further support (i.e., follow-up meetings) for the first six of these months if requested. Post-intervention, in the HIG a 23.5% and 39.0% reduction in canine (0.5% of total consultations, 95% confidence interval, 0.4-0.6, P = 0.04) and feline (4.4%, 3.4-5.3, P < 0.001) HPCIA-prescribing consultations was observed, compared to the CG (dogs: 0.6%, 0.5-0.8; cats: 7.4%, 6.0-8.7). The LIG was associated with a 16.7% reduction in feline HPCIA prescription (6.1% of total consultations, 5.3-7.0, P = 0.03). Therefore, in this trial we have demonstrated effective strategies for reducing veterinary HPCIA prescription.

Acute diabetic neuropathy following improved glycaemic control: a case series and review

SUMMARY

We present three cases of acute diabetic neuropathy and highlight a potentially underappreciated link between tightening of glycaemic control and acute neuropathies in patients with diabetes. Case 1: A 56-year-old male with poorly controlled type 2 diabetes (T2DM) was commenced on basal-bolus insulin. He presented 6 weeks later with a diffuse painful sensory neuropathy and postural hypotension. He was diagnosed with treatment-induced neuropathy (TIN, insulin neuritis) and obtained symptomatic relief from pregabalin. Case 2: A 67-year-old male with T2DM and chronic hyperglycaemia presented with left lower limb pain, weakness and weight loss shortly after achieving target glycaemia with oral anti-hyperglycaemics. Neurological examination and neuro-electrophysiological studies suggested diabetic lumbosacral radiculo-plexus neuropathy (DLPRN, diabetic amyotrophy). Pain and weakness resolved over time. Case 3: A 58-year-old male was admitted with blurred vision diplopia and complete ptosis of the right eye, with intact pupillary reflexes, shortly after intensification of glucose-lowering treatment with an SGLT2 inhibitor as adjunct to metformin. He was diagnosed with a pupil-sparing third nerve palsy secondary to diabetic mononeuritis which improved over time. While all three acute neuropathies have been previously well described, all are rare and require a high index of clinical suspicion as they are essentially a diagnosis of exclusion. Interestingly, all three of our cases are linked by the development of acute neuropathy following a significant improvement in glycaemic control. This phenomenon is well described in TIN, but not previously highlighted in other acute neuropathies.

LEARNING POINTS

A link between acute tightening of glycaemic control and acute neuropathies has not been well described in literature. Clinicians caring for patients with diabetes who develop otherwise unexplained neurologic symptoms following a tightening of glycaemic control should consider the possibility of an acute diabetic neuropathy. Early recognition of these neuropathies can obviate the need for detailed and expensive investigations and allow for early institution of appropriate pain-relieving medications.

Small animal disease surveillance: GI disease and salmonellosis

Presentation for gastrointestinal (GI) disease comprised 2.2 per cent of cat, 3.2 per cent of dog and 2.2 per cent of rabbit consultations between April 1, 2016 and March 31, 2017Diarrhoea and vomiting without blood were the most frequently reported GI disease clinical signs (34.4 and 38.9 per cent in cats and 42.8 and 37.3 per cent in dogs, respectively)The mean percentage of samples testing positive for Salmonella in dogs was double that in cats (0.82 per cent and 0.41 per cent, respectively) from January 1, 2011 to December 31, 2016In dogs, autumn was associated with a greater proportion of Salmonella-positive sample submissions; no clear suggestion of seasonal variation in cats was observedIn both cats and dogs, isolates belonging to Salmonella enterica group B serotypes were the most common (68.9 per cent in cats and 55.0 per cent in dogs).

Metabolic abnormalities among people diagnosed with schizophrenia: a literature review and implications for mental health nurses

Metabolic abnormalities such as diabetes, obesity and dyslipidaemia are found in much higher rates in people with a diagnosis of schizophrenia when compared with the general population. This review discusses the most prevalent metabolic abnormalities associated with schizophrenia, their frequency and implications for mental health nurses (MHN). This review illuminates the need for MHN to acquire added awareness, knowledge and practical strategies in managing people at high risk of developing metabolic abnormalities associated with MetS. By doing this, it contributes to the literature by highlighting practical strategies for MHN in assessment and ongoing monitoring of metabolic abnormalities in clinical practice. This review highlights the need for MHN to be vigilant in monitoring a person's physical state on commencement and throughout treatment with antipsychotics. There is a need for an early detection monitoring system for people who are potentially at risk of developing metabolic abnormalities. The literature review aimed to investigate metabolic abnormalities associated with metabolic syndrome (MetS) in people diagnosed with schizophrenia; they are almost twice as likely to have metabolic risk factors and die approximately 20 years younger than the general population. MetS has become an issue of growing concern in mental health nursing. A comprehensive literature review was conducted utilizing various databases to address the reviews aim. Databases such as CINAHL Plus with full text (via EBSCO), MEDLINE(R) (OVID), PsycINFO and the COCHRANE library were accessed. The main metabolic abnormalities that emerged were: diabetes, obesity and dyslipidaemia. Antipsychotic medication also plays a vital role in a person's susceptibility to the development of MetS. It is critical that MHN has access to training and education in managing people at high risk of developing metabolic abnormalities associated with MetS. This review contributes to the literature by highlighting practical strategies for MHN in assessment and ongoing monitoring of metabolic abnormalities in clinical practice.

The effect of level of crude protein and available lysine on finishing pig performance, nitrogen balance and nutrient digestibility

Two trials were conducted to investigate the effect of decreasing the crude protein (CP) content of diets for finishing pigs containing two levels of available lysine on nutrient digestibility, nitrogen (N) balance and production performance. Ten finishing diets containing five levels of CP (on average 144, 155, 168, 182 and 193 g/kg fresh basis) and two levels of available lysine (6.9 and 8.2 g/kg fresh basis) were formulated. The diets were offered to pigs on a performance trial (n = 800 Large White (LW)×Landrace (LR) pigs) from 10 wk of age until finish at 21 wks+5 d of age. Average daily gain (ADG), average daily feed intake (ADFI) and feed conversion ratio (FCR) were calculated. In addition, a digestibility/N balance trial was conducted using pigs (n = 80 LW×LR) housed in metabolism crates. Digestibility of dry matter (DM), CP, oil, fibre and energy was determined. N balance values were determined through analysis of N content of urine and faeces (‘as determined’). N balance values were also calculated using ADG values and assuming that 16% of growth is protein deposition (“as calculated”). Pig performance was poor between 10 and 13 wk of age which indicated that the dietary treatments were nutritionally inadequate for pigs less than 40 kg. There was a significant (p<0.01) quadratic effect of increasing CP level on feed intake, ADG and FCR from 10 to 13 wk which indicated that the lower CP levels did not supply adequate levels of essential or non-essential amino acids. There was no effect of increasing available lysine level throughout the early period, which in conjunction with the response in older pigs, suggested that both 8.2 and 6.9 g/kg available lysine were insufficient to drive optimum growth. There was a positive response (p<0.05) to increasing available lysine level from 13 wk to finish which indicated that 6.9 g/kg available lysine was not adequate for finishing pigs. Energy digestibility decreased with decreasing CP level of diets containing 6.9 g/kg available lysine which may be attributed to the higher fibre content of the lower CP diets. Nitrogen excretion (g/d) was lowered when dietary CP was reduced regardless of whether the values were determined through balance or calculated using ADG. Calculated N excretion decreased linearly (p<0.001) and quadratically (p<0.001) with decreasing dietary CP content. When the N balance figures calculated in this study were compared with those quoted in the Northern Ireland and English Nitrates Directive Action Programmes, N excretion was less per pig (wean to finish) offered a 169 g/kg CP, 8.2 g/kg available lysine diet (2.39 kg vs 3.41 kg (Northern Ireland) and 2.93 kg (England)).

Factors affecting self-care activities, postprandial plasma glucose and HbA1c in patients with type 2 diabetes

Focal points

Reflexology for the treatment of pain in people with multiple sclerosis: a double-blind randomised sham-controlled clinical trial

Multiple sclerosis (MS) results in pain and other symptoms which may be modified by conventional treatment, however, MS is still not curable. Several studies have reported positive effects of reflexology in the treatment of pain, however, no randomised controlled clinical trials for the treatment of pain have been conducted within this population. The objective of this study was to investigate the effectiveness of reflexology on pain in and MS population. We randomly allocated 73 participants to receive either precision or sham reflexology weekly for 10 weeks. Outcome measures were taken pre-and post-treatment with follow-up at 6 and 12 weeks by a researcher blinded to group allocation. The primary outcome measure recorded pain using a Visual Analogue Scale (VAS). A significant (p < 0.0001) and clinically important decrease in pain intensity was observed in both groups compared with baseline. Median VAS scores were reduced by 50% following treatment, and maintained for up to 12 weeks. Significant decreases were also observed for fatigue, depression, disability, spasm and quality of life. In conclusion, precision reflexology was not superior to sham, however, both treatments offer clinically significant improvements for MS symptoms via a possible placebo effect or stimulation of reflex points in the feet using non-specific massage.

The evolution of platelet-directed pharmacotherapy

The evolution of platelet directed pharmacotherapy in the prevention and treatment of patients with thrombotic disorders is based soundly on a rapidly expanding knowledge of platelet biology. Traditionally viewed, throughout most of its relatively brief history in medicine, as an anucleate, passive contributor to hemostasis, a more contemporary perspective acknowledges platelets as complex, multidimensional cells that participate actively in coagulation, vascular repair, angiogenesis and thrombosis within the micro and the macro-circulatory systems. Herein, we consider platelet-directed pharmacotherapy from these fundamental, biology-based exemplars--megakaryocytes, signal transduction and the platelet--coagulation protease interface. We also highlight the emerging biopharmacology platform of oligonucleotide platelet adhesion antagonists and their complementary antidotes.

100 years after Alzheimer: contemporary neurology practice assessment of referrals for dementia

BACKGROUND

The prevalence of dementia is placing an increased burden on specialists.

METHODS

Canadian neurologists responded to a structured questionnaire to assess reasons for referral and services provided as well as to compare the neurologists' perceptions of their practice characteristics against cases seen over a 3-month period.

RESULTS

The audit confirmed the participants' perception that family practitioners are the main referral source (358/453, 79%). Sixty-two percent of patients had undergone clinical investigation for dementia prior to being seen by the neurologist; 39% (177/453) were on pharmacotherapy at the time of referral, 68% were initiated on pharmacotherapy by the neurologist. A fifth of the referrals did not meet clinical criteria for dementia, which may be directly related to the prevalence of prior workup that did not include mental status testing.

CONCLUSIONS

Neurologists currently treat patients referred for dementia who may already have been adequately evaluated and treated by primary care providers.

“IT’S MORE THAN A PILL DROP”: ADHERENCE SUPPORT AND THE CLINICAL GAZE IN INNER CITY HOME-BASED HIV CARE

Background:Home-based HIV care has been identified as means of improving access to HIV care and reducing HIV-related stigma, while easing overload in facility-based care and providing cost effective community-based social supports. Few evaluations, however, focus on the impactof barriers such as homelessness, imprisonment and substance abuse to the continuity of this model of health care provision. This paper examines the challenges, strategies, and outcomes of a long-standing home-based HIV nursingprogram from a Foucauldian analytic perspective. Methods: Findings are presented from the evaluation of a home care nursing team providing HIV care to unstably housed individuals in Vancouver’s inner city. Employing ethnographic methodology, participant observation was conducted over nine months, along with serial open-ended qualitative interviews with the nursing team (n=4) and home care clients (n=16). Interviews were audio recorded and transcribed; an interpretive thematic analysis of field notes and interview transcripts was conducted. Results: Although adherence to antiretroviral therapy was consistent over the study course, men and women’s responses to care varied over time. Nurses who were sensitive to the ways in which enhanced surveillance within the private sphere of participants’ lives was cause for resistance to care employed a number of strategies to maintain these relationships. Variability among nurses regarding local (i.e. street) knowledge, along with understandings of what constitutes appropriate supportive measures, also impacted participants’ responses to care. Conclusions: The type and extent of support services is continually negotiated between nurses and participants, creating a potential source of tension between the guiding of health-related decisions and participants’ constitution of themselves as autonomous. Foucault’s concept of governmentality is applicable here, and may elucidate how norms, capacities and subjectivities are mutually created through its processes. The findings support an understanding of autonomy that is interpersonally, as well as institutionally, relational. Successful programming requires careful attention to the everyday experiences of participants, facilitated by continuity of providers andmentorship for newer nurses engaging in home-based HIV care. SuzeBerkhout is supported by the Canadian Institutes for Health Research, The Michael Smith Foundation for Health Research, Providence Health, and Vancouver Coastal Health Research Institute.

Heartburn-dominant, uninvestigated dyspepsia: a comparison of 'PPI-start' and 'H2-RA-start' management strategies in primary care--the CADET-HR Study

BACKGROUND

There are few data on empiric, stepped therapy for heartburn relief or subsequent relapse in primary care.

AIMS

To compare heartburn relief produced by a proton pump inhibitor-start or an H(2)-receptor antagonist-start with step-up therapy, as needed, followed by a treatment-free period to assess relapse.

METHODS

Heartburn-dominant uninvestigated dyspepsia patients from 46 primary care centres were randomized to one of two active treatment strategies: omeprazole 20 mg daily (proton pump inhibitor-start) or ranitidine 150 mg bid (H2-receptor antagonist-start) for the first 4-8 weeks, stepping up to omeprazole 40 or 20 mg daily, respectively, for 4-8 weeks for persistent symptoms. Daily diaries documented heartburn relief (score < or = 3/7 on < or = of 7 prior days) and relapse (score > or = 4 on > or = 2 of 7 prior days).

RESULTS

For 'proton pump inhibitor-start' (n = 196) vs. 'H2-receptor antagonist-start' (n = 194), respectively, heartburn relief occurred in 55.1% vs. 27.3% (P < 0.001) at 4 weeks and in 88.3% vs. 87.1% at 16 weeks. After therapy, 308 patients were heartburn-free (159 vs. 149); median times to relapse were 8 vs. 9 days and cumulative relapse rates were 78.6% vs. 75.8%, respectively.

CONCLUSIONS

An empiric 'proton pump inhibitor-start' strategy relieves heartburn more effectively than an 'H2-receptor antagonist-start' strategy up to 12 weeks but has no effect on subsequent relapse, which is rapid in most patients.

Traumatic injury of the thoracic duct

Injuries to the thoracic duct are infrequent but may become life-threatening when chylous leakage persists. This report describes 6 patients with such injuries in whom the leakage resolved spontaneously in one, was corrected using microsurgical lymphatic repair or lymphatic-venous anastomosis in two, successfully treated either by ligation of the thoracic duct or insertion of a peritoneovenous shunt in two, and was eventually controlled after bilateral pleurodesis and thoracic duct ligation by insertion of a peritoneo-venous shunt in one. Conventional lymphography is superior to lymphoscintigraphy and is usually required to document disruption of the thoracic duct.

Antibiotic prophylaxis is indicated for chest stab wounds requiring closed tube thoracostomy

To determine the role of antibiotic prophylaxis for stab wounds of the chest requiring intercostal tube drainage, a double-blind study was conducted comparing cefazolin, given to 57 patients at 500 mg every 8 h for 24 h, with placebo, given to 56. Differences were detected in the rate of thoracotomy for sepsis (antibiotic nil versus placebo 9 per cent, P < 0.05) and in the frequency of sputa positive for pathogens (12 versus 34 per cent respectively, P < 0.05), but the incidence of pyrexia, raised white cell count, positive cultures from pleural drainage or intercostal catheter tips and volume of chest drainage was similar. The mean hospital stay and costs consequent on morbidity were greater in patients receiving placebo, supporting the conclusion that antibiotic prophylaxis is indicated.

Risk for liver disease in adults with alpha 1-antitrypsin deficiency

Risk for the development of liver disease was estimated in 115 adults with alpha 1-antitrypsin deficiency, most of whom were of PI type (protease inhibitor type) Z. Seventy-one subjects were ascertained through their disease; 44 were ascertained independently of disease. A low concentration of serum prealbumin was sensitive in detecting impaired liver function and may indicate functioning cell mass, a different parameter than is measured by liver enzymes. Liver disease has usually been considered rare in adults with alpha 1-antitrypsin deficiency. However, the risk for the development of liver disease was relatively high for men between 51 and 60 years of age. The risk for women was lower than that for men. Our study indicates that a periodic assessment of liver function may be warranted for patients with alpha 1-antitrypsin deficiency who are over 40 years of age.

Three new rare variants of alpha 1-antitrypsin

Three new rare genetic variants of the serum protein alpha 1-antitrypsin (alpha 1-protease inhibitor) have been identified in a Caucasian population. The new alleles in the PI system are PI*EFRA, PT*PCAS, and PI*XALB. When compared with the normal type M by isolectric focusing in polyacrylamide, Efranklin (EFRA) is anodal, and Pcastoria (PCAS) and Xalban (XALB) are cathodal. These variants have been compared with previously described variants by isoelectric focusing and by electrophoresis in agarose and acid starch gels. All three variant alleles appear to be associated with normal amounts of alpha 1-antitrypsin, assayed both by functional and immunological methods.