Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003.

OBJECTIVE: To determine the contribution of infants born at the threshold of viability (defined as <750 g birth weight) and the role of regionalization of perinatal care on the neonatal mortality rate (NMR) in Colorado. STUDY DESIGN: We performed a retrospective cohort study, evaluating all live births in Colorado from 1991 to 2003, and comparing the periods 1991 to 1996 versus 1997 to 2003. RESULT: The overall unadjusted NMR of the two time periods was 4.3 and 4.4 per 1000 live births, respectively (P=0.42). The contribution of infants with birth weights<750 g to the overall NMR increased from 45.0 to 54.5% (P<0.01). The odds of death for infants<750 g increased between time periods (Odd ratio 1.3, 95% Confidence interval 1.11, 1.61). However, NMR decreased between time periods for all birth weight categories, until infants<600 g. With respect to regionalization, the number of infants<750 g born in a level III care center increased slightly between the two time periods (69.6 versus 73.3%; P=0.04); however, adjusted analysis showed no difference in the practice of regionalization between time periods. Regardless of time period, infants who weighed <750 g born in a level III center had 60% lower mortality risk when compared to <750 g infants born in a non-level III center (P<0.01; 95% CI 0.30, 0.52). CONCLUSION: Despite advances in neonatal medicine, the overall NMR in the state of Colorado remained unchanged between the time periods of 1991 to 1996 and 1997 to 2003. Infants at the threshold of viability continue to have a large impact on the Colorado NMR, making up a larger proportion of overall neonatal deaths. While the results demonstrate that the risk of mortality is significantly reduced for <750 g infants born in a level III center, the practice of regionalization has not changed between the two time periods. Improved efforts to standardize the referral practices to ensure delivery of <750 g infants in level III centers could potentially reduce the impact of these infants on the NMR. While the overall NMR in Colorado has not changed between the two time periods, the NMR for infants>600 g has significantly decreased, suggesting that the boundary delineating the threshold of viability needs reevaluation, as it may have been pushed lower than previously defined.

A randomized controlled trial of the psychosocial impact of providing internet training and access to older adults.

The Internet (electronic mail and the World Wide Web) may provide new opportunities for communication that can help older adults avoid social isolation. This randomized controlled trial assessed the psychosocial impact of providing Internet access to older adults over a five-month period. One hundred volunteers from four congregate housing sites and two nursing facilities were randomly assigned to receive Internet training or to a wait list control group. The pre & post measures included the UCLA Loneliness scale, modified CES Depression scale, a measure of locus of control, computer attitudes, number of confidants, and overall quality of life. Participants received nine hours of small group training in six sessions over two weeks. Computers were available for continued use over five months and the trainer was available two hours/week for questions. At the end of the trial, 60% of the intervention group continued to use the Internet on a weekly basis. Although there was a trend toward decreased loneliness and depression in intervention subjects compared to controls, there were no statistically significant changes from baseline to the end of trial between groups. Among Internet users (n = 29) in the intervention group there were trends toward less loneliness, less depression, more positive attitudes toward computers, and more confidants than among intervention recipients who were not regular users (n = 19) of this technology. Most elderly participants in this trial learned to use the Internet and the majority continued to use it on a weekly basis. The psychosocial impact of Internet use in this sample suggested trends in a positive direction. Further research is needed to determine more precisely, which older adults, residing in which environmental contexts are more likely than others to benefit from this rapidly expanding information and communication link.

Primary care for patients infected with human immunodeficiency virus: a randomized controlled trial.

OBJECTIVE: To measure the impact of a teaching intervention and to compare process and outcomes of care for HIV-infected patients randomly assigned to a general medicine clinic (GMC) or an infectious disease clinic (IDC) for primary care. DESIGN: Prospective, randomized, controlled trial. SETTING: University hospital in Durham, NC. PATIENTS: Two hundred fourteen consecutive HIV-infected patients presenting for primary care. INTERVENTION: Physicians at the GMC received HIV-related training and evidence-based practice guidelines. MEASUREMENTS: Utilization of services, health-related quality of life, preventive and screening measures, and antiretroviral use for one year. RESULTS: At baseline GMC patients were more likely to be African American (85% vs 71%; P =.03) and had lower baseline CD4+ cell counts than IDC patients (262 +/- 269 vs 329 +/- 275; P =.05). A similar and high proportion of patients in both groups received appropriate preventive care services including Pneumocystis carinii pneumonia (PCP) prophylaxis, pneumococcal vaccination, and antiretroviral therapy. Screening for TB was more frequent in GMC (89% vs 68%; P =.001). In the year following randomization, GMC patients made more visits to the emergency department than IDC patients (1.6 +/- 3.0 vs 0.7 +/- 1.5; P =.05). Hospital use was higher for GMC patients with average length of stay 7.8 +/- 6.3 days compared to 5.7 +/- 3.8 days for IDC patients (P =.01). In analyses, which adjust for potential baseline imbalances, these differences remained. CONCLUSIONS: Targeted education in GMC achieved similar provision of primary care for GMC patients, yet use of health care services was higher for this group. The delivery of adequate primary care is necessary but not sufficient to produce changes in health care utilization.

The human D1A dopamine receptor gene promoter directs expression of a reporter gene to the central nervous system in transgenic mice.

Dopamine receptors are involved in many aspects of dopaminergic neurotransmission including regulation of motor control, cognition, affect and neuroendocrine function. The D1A receptor is the most widely distributed dopamine receptor in the brain and is expressed at high levels in the striatum and nucleus accumbens, but is also found throughout cortical, limbic, hypothalamic and thalamic brain regions. We have cloned a 6.4 kb fragment 5' of the human D1A dopamine receptor gene and shown that this region activates transcription of the chloramphenicol acetyltransferase (CAT) gene in a cell-specific manner. To study the expression of these sequences in vivo we analyzed the expression of the E. coli lac Z gene under the regulation of the 6.4 kb fragment in transgenic mice. Expression of the transgene was primarily detected in the brain, with only low levels detected in peripheral tissues. The 5' flanking sequences were able to direct the tissue-specific expression of lac Z in three different lines of transgenic mice, to a number of brain regions including the caudate-putamen, thalamus, amygdala, cerebral cortex, hippocampus and hypothalamus. Greatest expression of the lac Z gene was detected in areas of the thalamus and amygdaloid complex. In the striatum, beta-galactosidase activity was restricted to neurons within the matrix and was not detected within striosomes. Results of this study demonstrate that the 6.4 kb region upstream of the human D1A receptor gene is sufficient to confer tissue-specific expression in the CNS of transgenic mice. Furthermore, expression of the transgene to neurons within the matrix of the striatum, but not the striosomes suggests that expression of the D1A receptor may be regulated differently within these areas.