Descriptive analyses of maternally-derived antibody levels against porcine circovirus 2 (PCV-2) in 3- and 21-day-old piglets from farms of four European countries using different vaccination protocols in sows.

BACKGROUND: Up to now, information on the levels of maternally-derived antibodies (MDA) against PCV-2 in suckling piglets born to sows vaccinated with different strategies is scarce in the literature. In the present observational study, the PCV-2-specific MDA titres from piglets from 109 farms (thirty 3-day-old and thirty 21-day-old piglets per farm) across four different European countries (France n = 30, Germany n = 27, Italy n = 22 and Spain n = 30) using different sow vaccination strategies (during gestation, as a gilt, as a piglet or never) were assessed. RESULTS: In all four countries, mean log PCV-2 MDA titres were higher in 3-day-old piglets than in the 3-week-old ones, being significant in most of all the comparisons performed. Within each country, the highest PCV-2-specific MDA titres were observed in the 3-day-old piglets born to sows vaccinated during gestation. Indeed, in the four countries, more than 60% of this subpopulation (3-day-old piglets from sows vaccinated during pregnancy) had the highest log PCV-2 titres detectable with the ELISA technique used in this study. The lowest MDA titres were more variable. Whereas in France and Germany the lowest titres corresponded to 21-day-old piglets born from sows vaccinated as a piglet, in Italy, they corresponded to 21-day-old piglets derived from sows vaccinated as a gilt and in Spain to 21-day-old piglets born from non-vaccinated sows. In this study, PCV-2-specific MDA titres at 3 and 21 days of age were not affected by sow parity. CONCLUSIONS: Data obtained could be considered as a European global overview of PCV-2-specific MDA titres present in the pre-vaccinated piglet populations in different European countries, with titres tending to be higher in younger piglets, but with values variable among countries and sow vaccination strategies.

Incommensurate stistaite--order made to order.

The structure of stistaite-SbSn, was investigated by single crystal X-ray diffraction and EDX to yield a simple relation between the modulated structure and the composition. Stistaite is found to be incommensurately ordered over the entire stability region.

State programs for medical diagnosis of child abuse and neglect: case studies of five established or fledgling programs.

OBJECTIVE: To describe the programs for medical diagnosis of child abuse and neglect in three states and efforts to establish state-wide programs in two states. To describe common themes and issues that emerged related to the establishment and maintenance of these programs. METHODS: Five states were selected as case studies to represent a range of experience and type of function embodied in programs that address medical diagnosis of child abuse and neglect. Individuals knowledgeable about the programs or efforts to establish state-wide programs in their home states described these in detail. Inductive analysis was used to identify themes and issues that emerged across the states studied. FINDINGS: Themes emerged in three general areas: funding, services, and training. Findings related to funding were: 1) State funding was vital for initiation of statewide programs; 2) Alliances with other groups with parallel interests were successfully used to garner support for child abuse programs; 3) Services needed to be adequately reimbursed to be sustained; 4) Political climate often affected funding. With regard to services we found: 1) There was no optimal way to organize services, but rather many ways that worked well; 2) It was critical to address local service needs; 3) Provision of standardized quality services was essential. With regard to training: 1) Professional training was an integral part of all statewide programs; 2) New technologies, including televideo, have been explored and implemented to assist in training in statewide programs. CONCLUSIONS: Each state has taken a unique approach to programs for the medical diagnosis of child abuse and neglect. However, there are commonalities, particularly among the states that have been successful in establishing and maintaining comprehensive services and/or training.

Childhood vaccine risk/benefit communication in private practice office settings: a national survey.

UNLABELLED: Communication about childhood vaccine risks and benefits has been legally required in pediatric health care for over a decade. However, little is known about the actual practice of vaccine risk/benefit communication. OBJECTIVES: This study was conducted to identify current practices of childhood vaccine risk/benefit communication in private physician office settings nationally. Specifically, we wanted to determine what written materials were given, by whom, and when; what information providers thought parents wanted/needed to know, the content of nurse and doctor discussion with parents, and the time spent on discussion. We also wanted to quantify barriers to vaccine risk/benefit discussion and to prioritize materials and dissemination methods preferred as solutions to these barriers. METHODS: We conducted 32 focus groups in 6 cities, and then administered a 27-question cross-sectional mailed survey from March to September 1998, to a random national sample of physicians and their office nurses who immunize children in private practices. Eligible survey respondents were active fellows of the American Academy of Pediatrics or American Academy of Family Physicians in private practice who immunized children and a nurse from each physician's office. After 3 mailings, the response rate was 71%. RESULTS: Sixty-nine percent of pediatricians and 72% of family physicians self-reported their offices gave parents the Centers for Disease Control and Prevention Vaccine Information Statement, while 62% and 58%, respectively, gave it with every dose. In ~70% of immunization visits, physicians and nurses reported initiating discussion of the following: common side effects, when to call the clinic and the immunization schedule. However, physicians reported rarely initiating discussion regarding contraindications (<50%) and the National Vaccine Injury Compensation Program (<10%). Lack of time was considered the greatest barrier to vaccine risk/benefit communication. Nurses reported spending significantly more time discussing vaccines with parents than pediatricians or family physicians (mean: 3.89 vs 9.20 and 3.08 minutes, respectively). Both physicians and nurses indicated an additional 60 to 90 seconds was needed to optimally discuss immunization with parents under current conditions. Stratified analysis indicated nurses played a vital role in immunization delivery and risk/benefit communication. To improve vaccine risk/benefit communication, 80% of all providers recommended a preimmunization booklet for parents and approximately one half recommended a screening sheet for contraindications and poster for immunization reference. The learning method most highly endorsed by all providers was practical materials (80%). Other desirable learning methods varied significantly by provider type. CONCLUSIONS: There was a mismatch between the legal mandate for Vaccine Information Statement distribution and the actual practice in private office settings. The majority of providers reported discussing some aspect of vaccine communication but 40% indicated that they did not mention risks. Legal and professional guidelines for appropriate content and delivery of vaccine communication need to be clarified and to be made easily accessible for busy private practitioners. Efforts to improve risk/benefit communication in private practice should take into consideration the limited time available in an office well-infant visit and should be aimed at both the nurse and physician.

Barriers to smoking cessation initiatives for Medicaid clients in managed care.

In this paper, key barriers to providing smoking cessation services for low income individuals are illustrated using epidemiologic data from a population which was enrolled in a Medicaid managed care plan in Kansas during 1998. The Plan served 623 pregnant women who could potentially benefit from assistance in avoiding tobacco exposure. The prevalence of smoking among adult clients was 44.8%. twice the national average. Only 52.3% of adult smokers were advised by a provider to quit in the previous year. Most individuals in the client population (81.7% of the 10,733 members) were children, suggesting the importance of targeting environmental tobacco smoke exposure in order to reduce morbidity from asthma. The adult household member who needed smoking cessation services, however, was unlikely to qualify for health care benefits through Medicaid. The median length of enrollment was only 1.9 months, providing very little client contact time for tobacco control initiatives. The literature suggests that some providers may lack skills in treating tobacco as an addiction. It would be a major task for the managed care organization to train the 2,000 physicians in 68 of the 105 counties of Kansas who cared for this population. Potential solutions include improving reimbursement for smoking prevention and treatment, and developing cheaper smoking cessation services which are effective and acceptable among low-income individuals. The managed care organization could provide patient education materials and staff training for physicians and other members of the office staff.

Complete genomic sequence of the human ABCA1 gene: analysis of the human and mouse ATP-binding cassette A promoter.

The ABCA1 gene, a member of the ATP-binding cassette A (ABCA1) transporter superfamily, encodes a membrane protein that facilitates the cellular efflux of cholesterol and phospholipids. Mutations in ABCA1 lead to familial high density lipoprotein deficiency and Tangier disease. We report the complete human ABCA1 gene sequence, including 1,453 bp of the promoter, 146,581 bp of introns and exons, and 1 kb of the 3' flanking region. The ABCA1 gene spans 149 kb and comprises 50 exons. Sixty-two repetitive Alu sequences were identified in introns 1-49. The transcription start site is 315 bp upstream of a newly identified initiation methionine codon and encodes an ORF of 6,783 bp. Thus, the ABCA1 protein is comprised of 2,261 aa. Analysis of the 1,453 bp 5' upstream of the transcriptional start site reveals multiple binding sites for transcription factors with roles in lipid metabolism. Comparative analysis of the mouse and human ABCA1 promoter sequences identified specific regulatory elements, which are evolutionarily conserved. The human ABCA1 promoter fragment -200 to -80 bp that contains binding motifs for SP1, SP3, E-box, and AP1 modulates cellular cholesterol and cAMP regulation of ABCA1 gene expression. These combined findings provide insights into ABCA1-mediated regulation of cellular cholesterol metabolism and will facilitate the identification of new pharmacologic agents for the treatment of atherosclerosis in humans.

Human ATP-binding cassette transporter 1 (ABC1): genomic organization and identification of the genetic defect in the original Tangier disease kindred.

Tangier disease is characterized by low serum high density lipoproteins and a biochemical defect in the cellular efflux of lipids to high density lipoproteins. ABC1, a member of the ATP-binding cassette family, recently has been identified as the defective gene in Tangier disease. We report here the organization of the human ABC1 gene and the identification of a mutation in the ABC1 gene from the original Tangier disease kindred. The organization of the human ABC1 gene is similar to that of the mouse ABC1 gene and other related ABC genes. The ABC1 gene contains 49 exons that range in size from 33 to 249 bp and is over 70 kb in length. Sequence analysis of the ABC1 gene revealed that the proband for Tangier disease was homozygous for a deletion of nucleotides 3283 and 3284 (TC) in exon 22. The deletion results in a frameshift mutation and a premature stop codon starting at nucleotide 3375. The product is predicted to encode a nonfunctional protein of 1,084 aa, which is approximately half the size of the full-length ABC1 protein. The loss of a Mnl1 restriction site, which results from the deletion, was used to establish the genotype of the rest of the kindred. In summary, we report on the genomic organization of the human ABC1 gene and identify a frameshift mutation in the ABC1 gene of the index case of Tangier disease. These results will be useful in the future characterization of the structure and function of the ABC1 gene and the analysis of additional ABC1 mutations in patients with Tangier disease.

A polio immunization pamphlet with increased appeal and simplified language does not improve comprehension to an acceptable level.

We used a randomized trial to compare two polio vaccine pamphlets written on a sixth grade level--the vaccine information statement prepared by the Centers for Disease Control (CDC) and an easy-to-read pamphlet we developed (LSU)--for reading ability, comprehension and preference among 610 parents with a broad range of demographic characteristics. Parents at all reading levels and incomes preferred LSU (76% vs. 21%, P < 0.001). Although readers of LSU achieved significantly higher comprehension (65% vs. 60%, P < 0.05) this difference may not be clinically significant. The information items presented with instructional graphics were the only items on which differences in comprehension levels achieved both clinical and statistical significance. Comprehension was lowest for the CDC mandated information on risks and the National Injury Compensation. Our findings demonstrate that simplifying written immunization material and making it more suitable will increase appeal, but such modification may not raise comprehension to an acceptable level without use of instructional graphics. Health education materials intended for general parent populations, which are written on a sixth grade reading level, may not adequately educate parents or prepare them for a discussion with their physicians.

Tissue-type plasminogen activator is a target of the tumor suppressor gene maspin.

The maspin protein has tumor suppressor activity in breast and prostate cancers. It inhibits cell motility and invasion in vitro and tumor growth and metastasis in nude mice. Maspin is structurally a member of the serpin (serine protease inhibitors) superfamily but deviates somewhat from classical serpins. We find that single-chain tissue plasminogen activator (sctPA) specifically interacts with the maspin reactive site loop peptide and forms a stable complex with recombinant maspin [rMaspin(i)]. Major effects of rMaspin(i) are observed on plasminogen activation by sctPA. First, rMaspin(i) activates free sctPA. Second, it inhibits sctPA preactivated by poly-D-lysine. Third, rMaspin(i) exerts a biphasic effect on the activity of sctPA preactivated by fibrinogen/gelatin, acting as a competitive inhibitor at low concentrations (< 0.5 microM) and as a stimulator at higher concentrations. Fourth, 38-kDa C-terminal truncated rMaspin(i) further stimulates fibrinogen/gelatin-associated sctPA. rMaspin(i) acts specifically; it does not inhibit urokinase-type plasminogen activator, plasmin, chymotrypsin, trypsin, or elastase. Our kinetic data are quantitatively consistent with a model in which two segregated domains of maspin interact with the catalytic and activating domains of sctPA. These complex interactions between maspin and sctPA in vitro suggest a mechanism by which maspin regulates plasminogen activation by sctPA bound to the epithelial cell surface.

Prevalence of hypertension in patients with type II diabetes in referral versus primary care clinics.

We compared the prevalence of hypertension in patients with non-insulin-dependent diabetes mellitus (NIDDM) in referral and primary care practices using definitions of The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V), while controlling for other risk factors such as hypertension, obesity, smoking, and age. Patients (n = 1443) were enrolled consecutively from a large referral practice at the Jackson Diabetes Center and four primary care clinics in the vicinity. Blood pressures were measured at three clinic visits after a 5-min rest in a sitting position using a standard clinical sphygmomanometer. Charts were reviewed to determine diabetes duration, insulin usage, height, weight, smoking history, use of antihypertensive and oral hypoglycemic medications, socioeconomic status, and race. Patients were classified as hypertensive based on JNC-V definitions or if they were on antihypertensive medication. Hypertension was termed uncontrolled if blood pressure was JNC-V Stage 2 or higher while on antihypertensive medication. Seventy-eight percent of referral clinic and 55% of primary care clinic patients had either JNC-V State 1 or higher hypertension or were on antihypertensive medication. Actual blood pressures indicated that more patients had JNC-V Stage 1 (mild) or higher hypertension in referral compared to primary care clinics (62% versus 48% p = 0.01) but fewer had JNC-V Stage 2 or higher (moderate-severe) hypertension (12% versus 19% p = 0.002). Patients seen in the referral clinic were significantly more likely to have greater age, greater duration of diabetes, higher insulin dosage, longer smoking history, antihypertensive medication, and live outside the metropolitan area. By logistic regression, the odds of hypertension were significantly increased with age (OR 1.51/decade), BMI greater than 27 (OR 2.17), diabetes duration (OR 1.04/year), and insulin dosage (OR 1.74/U/kg). Current smoking and attending a referral clinic were not significantly related. The odds of moderate-severe hypertension were significantly increased with age (OR 1.23/ decade), decreased by attending a referral clinic (OR 0.45), and not significantly related to other confounders in the model. The prevalence of hypertension among patients with NIDDM was higher in referral than primary care clinics. The higher prevalence in the referral practice can be accounted for by the greater severity of associated risk factors in the referral practice patients; however, most patients will be diagnosed and treated for hypertension prior to referral. More patients in the referral practice were on hypertensive medication, which lowered the stage or severity of hypertension but still not to the normal range. The results suggest that the primary detection of hypertension in patients with type II diabetes resides with the primary care physician. Management of hypertension will require both a delineation and acceptance of responsibilities between the primary care physician and diabetes specialists.

Parent comprehension of polio vaccine information pamphlets.

BACKGROUND: Medical information pamphlets often are written using language that requires a reading level higher than parents of many pediatric patients have achieved. Anecdotal reports suggest that many parents may not readily understand the federally mandated Public Health Service vaccine information pamphlets prepared by the Centers for Disease Control and Prevention (CDC) in 1991. The level at which the pamphlets need to be written for low-reading-level parents is undetermined, as is whether parents reading at higher levels will accept low-reading-level materials. METHODS: To determine whether a simple pamphlet prepared at a low reading level using qualitative and adult education techniques would be preferable to the available CDC polio vaccine information pamphlet, we conducted an integrated qualitative-quantitative study. We compared the parent reading time and comprehension of a simplified pamphlet (Louisiana State University, LSU) comprising 4 pages, 322 words, 7 instructional graphics, and a text requiring a 6th grade reading ability with the equivalent 1991 CDC vaccine information pamphlet comprising 16 pages, 18,177 words, no graphics, and a text requiring a 10th grade reading level. We measured the reading ability of 522 parents of pediatric patients from northwest Louisiana seen at public clinics (81%) and in a private office (19%). Of the entire group, 39% were white, 60% African-American, and 1% Hispanic; the mean age was 29 years; the mean highest grade completed was 12th grade 3 months; and the reading level was less than 9th grade in 47% of parents and less than 7th grade in 20%. After parents were given one of the pamphlets to read, their reading time, comprehension, and attitude toward the pamphlet were measured. RESULTS: Mean comprehension was 15% lower for CDC than for LSU (56% vs 72% correct; P < .001) and reading time was three times longer for CDC than for LSU (13 minutes 47 seconds vs 4 minutes 20 seconds; P < .0001). These trends were significant for parents reading at all but the lowest levels. Mean comprehension and reading time did not differ among parents reading at the third grade level or less. However, mean comprehension was greater and reading time lower for LSU among parents at all reading abilities greater than the third grade. Parents in the private practice setting took the longest time to read the CDC (20 minutes 59 seconds vs 5 minutes 46 seconds, LSU), yet their comprehension on the LSU was significantly higher than on the CDC (94% vs 71%; P < .0001). Two focus groups of high-income parents were unanimous in preferring the LSU. CONCLUSIONS: A short, simply written pamphlet with instructional graphics was preferred by high- and low-income parents seen in private and public clinics. The sixth grade reading level appears to be too high for many parents in public clinics; new materials aimed at third to fourth grade levels may be required. The new 1994 CDC immunization materials, written at the eighth grade level, may still be inappropriately high. The American medical community should adopt available techniques for the development of more effective patient-parent education materials.

Breast feeding and the development of juvenile rheumatoid arthritis.

OBJECTIVE: To determine if children with juvenile rheumatoid arthritis (JRA) are less likely to have been breast fed than controls. METHODS: Case-control study of data obtained from a survey of mothers 54 children with JRA and 79 playmates regarding breast feeding. Duration of breast feeding was tabulated and odds ratios (OR) with 95% confidence intervals (CI) were determined. RESULTS: OR for breast feeding in children with JRA was 0.40 (0.20-0.81, 95% CI) compared to playmates. For pauciarticular JRA (N = 28) OR was 0.31 (0.10-0.93); in polyarticular JRA (N = 24) OR was 0.60 (0.21-1.70). Lower OR for increased durations of breast feeding were noted in children with JRA. CONCLUSION: Children who have had JRA, especially pauciarticular JRA, are less likely to have been breast fed than controls, suggesting that breast feeding may have a protective effect on the development of JRA.

Reading grade levels and health behaviors of parents at child clinics.

OBJECTIVES: Recent reports suggest alarmingly low levels of literacy among adults in the U.S., but these are not expressed in grade levels. Assessment of the epidemiology of reading grade levels is necessary for development of patient education materials written at appropriate levels. METHODS: We measured demographics, reading ability and self-described health behaviors of 646 parents at two private, two university, two indigent and six public child-related clinics in a midwestern city using a bilingual oral interview and the Wide Range Achievement Test. RESULTS: Parents were 59% white, 92% female, with mean age 28 years, mean years of school 12.1 and mean reading grade 8.7. Parents tended to read four to five grades below their highest completed school grade. Analysis of self-reported health behaviors showed that 69% had no private insurance, 31% smoked cigarettes, 35% had body mass index greater than 27, and 46% of parous mothers had never breast-fed. Prevalence odds ratios showed that all adverse health risks except obesity were associated with low reading ability. CONCLUSIONS: These findings have important implications for public health professionals working in clinical care, health education and agency policy. Persons with low literacy levels appear to be at particularly high risk for adverse health behaviors. Education materials and teaching vocabulary should be appropriate for client reading grade levels.

Reading ability of parents compared with reading level of pediatric patient education materials.

OBJECTIVES: To test the reading ability of parents of pediatric outpatients and to compare their reading ability with the ability necessary to read commonly used educational materials; to compare individual reading grade levels with the levels of the last grade completed in school; and to further validate a new literacy screening test designed specifically for medical settings. DESIGN: Prospective survey. SETTING: Pediatrics outpatient clinic in a large, public university, teaching hospital. PARTICIPANTS: Three hundred ninety-six parents or other caretakers accompanying pediatric outpatients. MEASUREMENTS: Demographics and educational status were assessed using a structured interview. Reading ability was tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test-Revised. Written educational materials were assessed for readability levels with a computer program (Grammatik IV). RESULTS: The mean score on the REALM for all parents placed them in the seventh to eighth grade reading range, despite the mean self-reported last grade completed in school being 11th grade 5th month. Wide Range Achievement Test-Revised scores correlated well with REALM scores (0.82). Eighty percent of 129 written materials from the American Academy of Pediatrics, the Centers for Disease Control, the March of Dimes, pharmaceutical companies, and commercially available baby books required at least a 10th grade reading level. Only 25% of 60 American Academy of Pediatrics items and 19% of all materials tested were written at less than a ninth grade level, and only 2% of all materials were written at less than a seventh grade level. CONCLUSION: This study demonstrates that parents' self-reported education level will not accurately indicate their reading ability. Testing is needed to screen at-risk parents for low reading levels. In a public health setting, a significant amount of available parent education materials and instructions require a higher reading level than most parents have achieved. In such settings, all materials probably should be written at less than a high school level if most parents are to be expected to read them. The REALM can easily be used in busy public health clinics to screen parents for reading ability.