Idiopathic osteosclerosis mimicry of a tooth: case report.

This report presents two cases of idiopathic osteosclerosis involving the maxilla and mandible which were identified as a buccally impacted canine and a retained root, respectively, on clinical and plain radiographical examinations. Both patients were females who presented with hypodontia. Radiographic evaluation revealed solitary well-defined radiopaque masses with thickened cortical border. Both patients were undergoing orthodontic treatment and one was planned for a surgical traction of unerupted tooth prior to cone-beam CT assessment. In this report, we reviewed the clinical findings and explained the radiographic appearance of idiopathic osteosclerosis through plain radiographs and cone-beam CT to facilitate its identification among general dentists and oral and maxillofacial radiologists.

Optimizing CT angiography in patients with Fontan physiology: single-center experience of dual-site power injection.

AIM: To identify adult patients with single-ventricle congenital heart disease and Fontan procedure palliation who have been misdiagnosed with or incompletely evaluated for pulmonary embolism. Additionally, this study was designed to demonstrate that simultaneous, dual-injection of contrast medium into an upper and lower extremity vein is superior to single-injection protocols for CT angiography (CTA) of the chest in this population. MATERIALS AND METHODS: Patients included in the study were retrospectively selected from the Adult Congenital Heart Disease (ACHD) database. Search criteria included history of Fontan palliation and available chest CT examination. Patients were evaluated for (1) type of congenital heart disease and prior operations;(2) indication for initial CT evaluation;(3) route of contrast medium administration for the initial CT examination and resulting diagnosis;(4) whether or not anticoagulation therapy was initiated; and (5) final diagnosis and treatment plan.Results: The query of the ACHD database resulted in 28 individuals or patients with Fontan palliation (superior and inferior venae cavae anastomosed to the pulmonary arteries). Of these, 19 patients with Fontan physiology underwent CTA of the pulmonary circulation, and 17 had suboptimal imaging studies. Unfortunately, seven of these 17 patients (41%) were started on anticoagulation therapy due to a diagnosis of pulmonary embolism that was later excluded. CONCLUSION: Patients with single-ventricle/Fontan physiology are at risk of thromboembolic disease. Therefore, studies evaluating their complex anatomy must be performed with the optimal imaging protocol to ensure diagnostic accuracy, which is best achieved with dual-injection of an upper and lower extremity central vein.

Comparison of the Brucella Standard Agglutination Test with the ELISA IgG and IgM in patients with Brucella bacteremia.

The presumptive diagnosis of Brucellosis is based on a high or rising antibody titer measured by the Brucella Standard Agglutination Test (SAT). This tests does not discriminate between the immunoglobulin classes (IgG and IgM). The purpose of this study was to compare the diagnostic value of SAT with Brucella Enzyme Linked Immunosorbent Assay (ELISA) IgG and IgM tests in patients with Brucella bacteremia. Over a one-year period, we had 68 patients with clinical features suggestive of Brucellosis who had positive blood cultures for Brucella species. Sera were obtained from all of the patients as well as a control group of 70 healthy military personnel who were blood donors and had no symptoms of Brucellosis. Patients and blood donors originated from the same referral population. All the sera were tested by SAT and ELISA. All the 70 controls had a negative SAT. The sensitivity and specificity of the SAT test for the bacteremic patients were 95.6% and 100.0% respectively, while that of the ELISA IgG were 45.6% and 97.1%, and that of the ELISA IgM were 79.1% and 100.0% respectively. The sensitivity and specificity of either IgG or IgM positivity were 94.1% and 97.1% respectively. Assuming that the population prevalence of active Brucellosis in Saudi Arabia (SAT >or=1:320) is 5%, the positive and negative predictive values of SAT were 100% and 99.7% respectively; of ELISA IgG they were 45.2% and 97.1%; and of ELISA IgM they were 100% and 98.9%. When both the ELISA IgG and IgM were combined, the positive and negative predictive values were 63% and 99.6% respectively. In patients with Brucella bactremia, the sensitivity of either ELISA IgM or IgG were lower than SAT, however, combining IgM and IgG had similar sensitivity and specificity to SAT. The positive predictive value of SAT and IgM is satisfactory.

Outbreak of Acinetobacter baumannii in an intensive care unit associated with tracheostomy.

A case-control study was conducted to determine risk factors for acquisition of an epidemic strain of Acinetobacter baumannii in an intensive care unit. The epidemic strain was identified by pulsed-field gel electrophoresis and was isolated from tracheal secretions in 13 (87%) of 15 patients. In a logistic regression analysis, presence of a tracheostomy was an independent risk for Acinetobacter sp acquisition (odds ratio, 421; 95% confidence interval, 13.8-12925; P =.001) and the strength of the association was inversely related to the duration of mechanical ventilation. The outbreak coincided with the introduction of a policy of early percutaneous tracheostomy in the intensive care unit and probably resulted from inadequate infection control practices during respiratory care. No environmental reservoir was found. Institution of contact precautions, enhanced handwashing, and staff education was associated with resolution of the outbreak.

A randomized clinical trial to compare the effects of a heat and moisture exchanger with a heated humidifying system on the occurrence rate of ventilator-associated pneumonia.

BACKGROUND: The purpose of this study was to compare the performance of heat and moisture exchanger filters with heated humidifying systems in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and bacterial colonization. METHOD: Two hundred and forty-three consecutive patients who required mechanical ventilation for 48 hours or more in the adult intensive care unit were randomized to either a heat and moisture exchanger (HME) or a heated humidifying breathing circuit. RESULTS: The VAP rate among the group with HME was 11.4%; the rate among the group with heated humidifying system (HHS) was 15.8%. The difference was not statistically significant. Approximately 68% of the patients in the HME group had no pathogen isolated compared with 50% of the patients in the HHS group. This difference was statistically significant (P =.006). However, the distribution of the pathogens among those patients who had the isolated pathogens was mostly identical in the 2 groups. CONCLUSION: Even though the study did not find HME to be significantly advantageous over the HHS, in as much as VAP rate is concerned, other advantages such as reduced nurses workload, reduced financial cost, and better safety made HME a more favorable device for use in our adult intensive care unit.

The correlation of agglutination titer with positive blood cultures in brucellosis: A comparison of two study periods.

Brucellosis is an endemic zoonosis in Saudi Arabia. Correlation of Brucella agglutination antibody titer with positive blood culture was performed over 2 time periods (1986 and 1998). At the King Fahad National Guard Hospital we generally consider a titer value of 1:320 or greater as being diagnostic of Brucella. Using this cut-off, the positive predictive value of 39.3% (95% CI=31.5 to 47.6) in the 1986 study increased to 55.7% (95% CI=42.4 to 68.5) in the recent study (P=0.03). This improvement is probably due to parallel improvement in both methodologies.

Directed evolution of new glycosynthases from Agrobacterium beta-glucosidase: a general screen to detect enzymes for oligosaccharide synthesis.

BACKGROUND: Oligosaccharide synthesis is becoming increasingly important to industry as diverse therapeutic roles for these molecules are discovered. The chemical synthesis of oligosaccharides on an industrial scale is often prohibitively complex and costly. An alternative, that of enzymatic synthesis, is limited by the difficulty of obtaining an appropriate enzyme. A general screen for enzymes that catalyze the synthesis of the glycosidic bond would enable the identification and engineering of new or improved enzymes. RESULTS: Glycosynthases are nucleophile mutants of retaining glycosidases that efficiently catalyze the synthesis of the glycosidic linkage by condensing an activated glycosyl fluoride donor with a suitable acceptor sugar. A novel agar plate-based coupled-enzyme screen was developed (using a two-plasmid system) and used to select an improved glycosynthase from a library of mutants. CONCLUSIONS: Plate-based coupled-enzyme screens of this type are extremely valuable for identification of functional synthetic enzymes and can be applied to the evolution of a range of glycosyl transferases.

Near point-source longitudinal and transverse mode ultrasonic arrays for material characterization.

Specially constructed near point-source ultrasonic transducers (0.75 MHz) were designed to preferentially stimulate and receive the one longitudinal (P) and two transverse (S) propagation modes. Arrays of these transducers were placed on a rectangular prism of common sodalime glass, which served as an ideal homogeneous, isotropic medium, to evaluate the uncertainty of a newly developed phase velocity measurement method. Through the use of the Radon transform, the data were transformed from the offset-time (x-t) domain to the intercept time--horizontal slowness (tau-p) domain. From the shape of the curves in the tau-p domain, the phase velocity of the propagating waves may be determined for a range of directions. The phase velocities determined using this method were accurate for incidence angles up to 76 degrees, 64 degrees, and 77 degrees for the P, SV, and SH wave modes, respectively. Phase velocities of 5724 +/- 64, 3411 +/- 30, and 3467 +/- 15 m/s were determined for the P-wave, SV-wave, and SH-wave modes, respectively. This agrees with the direct transmission P-wave and S-wave velocities of 5690 +/- 60 and 3440 +/- 26 m/s, respectively, to better than 1%.

Impact of antibiotic prophylaxis on wound infection after cesarean section in a situation of expected higher risk.

BACKGROUND: To measure rates of incisional surgical site infection (ISSI) after cesarean section (CS) and to assess risks for infection. METHODS: Prospective surveillance for ISSI at a 540-bed hospital in Saudi Arabia by using Centers for Disease Control and Prevention definitions for infection and the National Nosocomial Infections Surveillance (NNIS) system risk index. RESULTS: Seven hundred thirty-five CSs were studied from September 1998 to July 1999; 72% were emergency procedures, despite a 95% rate of antenatal care. The overall ISSI rate was 2.8% (95% confidence interval [CI], 1.7%-4.3%). The rate for NNIS risk category 0 was 2.4% (95% CI, 1.3%-4.2%; n = 536) and for category 1 was 4.1% (95% CI, 1.8%-8.6%; n = 170). In the multivariate analysis, the only independent risks for ISSI were duration of surgery (OR = 1.01; 95% CI, 1.00-1.03; P =.02) and no antibiotic prophylaxis (OR = 3.09; 95% CI, 1.10-9.11; P =.04). Antibiotic prophylaxis was inconsistently administered among both emergency and elective CS. Infection control procedures were inadequate in the obstetric suite operating room. CONCLUSIONS: Despite deficient infection control practices in the setting described, ISSI rates after CS were judged "acceptable" compared with NNIS benchmark rates. This was attributed to prescribing antibiotic prophylaxis for patients at low risk as well as high risk of infection.

Brucellosis in pregnant women.

Brucella species occasionally cause spontaneous human abortion, but theories regarding whether they do so more frequently than do other infectious pathogens remain controversial. We reviewed 92 pregnant women who presented with acute brucellosis at a Saudi Arabian hospital. From 1983 through 1995, the cumulative incidence of pregnancy and brucellosis was 1.3 cases per 1000 delivered obstetrical discharges. The incidence of spontaneous abortion in the first and second trimesters was 43%, and the incidence of intrauterine fetal death in the third trimester was 2%. Antepartum antimicrobial therapy with cotrimoxazole or cotrimoxazole/rifampin was protective against spontaneous abortion (relative risk, 0.14; 95% confidence interval, 0.06--0.37; P<.0001). The beneficial effect of treatment occurred in women with febrile illness; vaginal bleeding at presentation usually led to spontaneous abortion. This study demonstrated that the incidence of spontaneous abortion among pregnant women with brucellosis is high and that these women should receive prompt therapy with antimicrobial agents when they present for medical care.

Are Saudi Arabian hospitals prepared for the threat of biological weapons?

The use of biological weapons has been recorded repeatedly in history. Until recently, biological terrorism had been little discussed or written about. However, events over the past 12 to 18 months have made it clear that likely perpetrators already envisage every possible scenario. Nations and dissident groups exist that have both the motivation and access to utilize biological weapons. In April 1994, a Russian biological weapons expert presented the conclusions of the Russian experts as to the agents most likely to be used: smallpox, anthrax, and plague. Health care workers in the Kingdom of Saudi Arabia (physicians, nurses, and emergency medical technicians) need to be aware of the seriousness of the threat of biological weapons, and to have an approach for the early identification, triage, and management of biological weapons victims. Clues to the occurrence of a bioterrorism attack include the abrupt onset of a large number of cases of a similar disease or syndrome, the occurrence of diseases with unusual geographic or seasonal distribution, and epidemics of non-endemic diseases. Health care workers must maintain a high index of suspicion, involve the hospital epidemiologist or infectious diseases specialist, identify a clear administrative chain-of-command to minimize confusion, and rely on existing networks such as the hospital disaster-and-safety committee to ensure a multidisciplinary response. Maximum readiness can be achieved by periodic readiness drills.

Brucellosis in laboratory workers at a Saudi Arabian hospital.

BACKGROUND: Saudi Arabia is hyperendemic for brucellosis, with more than 8000 cases reported each year to public health authorities. During 1998, brucellosis ranked as the No. 1 reportable communicable disease (22.5%) in Saudi Arabian National Guard communities. King Fahad Hospital is the major referral center for National Guard personnel in the nation's central region. METHODS AND RESULTS: From 1991 to 2000, brucellosis developed in 7 expatriate hospital employees. Six employees were bacteriology technologists, and one was a pathologist. Each had a clinical syndrome compatible with brucellosis (headache, fever, rigors, sweats, and myalgias) plus elevated Brucella sp serum agglutinin titers > or = 1:1280; one patient also had positive blood cultures. All patients responded to anti-Brucella therapy. Two patients had relapses, and complications occurred in four patients (septic endophlebitis of the leg, infected prosthesis, epididymoorchitis, and lumbar spondylitis). In all these employees except the pathologist, the infection was associated with processing Brucella sp cultures. CONCLUSION: Despite the enforcement of stringent infection control measures including the use of a class II biosafety hood in the laboratory, the problem of nosocomial brucellosis persists because of the large number of infected specimens handled by the laboratory (17,500 specimens per year). Ultimately, risk reduction depends on efforts to reduce disease endemicity in the country. In the meantime, conversion of the laboratory to biosafety level 3 is under way.

Structural characterization of a low density lipoprotein receptor-active apolipoprotein E peptide, ApoE3-(126-183).

Apolipoprotein E (apoE) plays a critical role in lipoprotein particle clearance from blood plasma through its interaction with the low density lipoprotein (LDL) receptor and other related receptors. Here, we studied a 58-residue peptide encompassing the receptor binding region of apoE. ApoE3-(126-183) was generated by cyanogen bromide cleavage of recombinant apoE3-(1-183), purified by reversed-phase high pressure liquid chromatography, and characterized by mass spectrometry. Far UV CD spectroscopy of the peptide showed that it is unstructured in aqueous solution. The addition of trifluoroethanol or dodecylphosphocholine induces the peptide to adopt an alpha-helical conformation. ApoE3-(126-183) efficiently transforms dimyristoylphosphatidylglycerol (DMPG) vesicles into peptide-lipid complexes. Analysis of apoE3-(126-183). DMPG complexes by electron microscopy revealed disc-shaped particles with an average diameter of 13 +/- 3 nm. Flotation equilibrium analysis yielded a particle molecular mass of 252 kDa. Far UV CD analysis of apoE3-(126-183).DMPG discs provided evidence that the peptide adopts a helical conformation. Competition binding experiments with (125)I-labeled low density lipoprotein (LDL) were conducted to assess the ability of apoE3-(126-183).DMPG complexes to bind to the LDL receptor. Both N-terminal apoE and the peptide, when complexed with DMPG, competed with (125)I-LDL for binding sites on the surface of cultured human skin fibroblasts. Under the conditions employed, apoE3-(126-183).DMPG complexes were similar to apoE3-(1-183).DMPG discs in their ability to bind to the receptor, demonstrating that the peptide represents a good model to study the interaction between apoE and the LDL receptor. Preliminary NMR results indicated that a high resolution structure of the apoE3-(126-183) peptide is obtainable.

Ophthalmic manifestations of Angelman syndrome.

In 1965, Angelman described 3 cases of what he called "Puppet" children, named for the characteristic signs associated with what is now known as Angelman syndrome, including mental retardation, speech impairment, easy excitability, and frequent spontaneous laughter.(1) Since that report, much progress has been made in defining the syndrome's clinical manifestations and understanding its molecular foundations, including identification of deletions of 15q11-13 in some patients. There are few reports in the ophthalmic literature regarding ocular manifestations of this syndrome. (2,3) We present the case of a child with strabismus associated with Angelman syndrome, and we review the ophthalmic and systemic findings, as well as recent advances in molecular genetics, in these patients.

Entoptic perimetry screening for central diabetic scotomas and macular edema.

OBJECTIVE: The aim of this study was to compare entoptic perimetry, using conventional television, to Amsler grid and patient-reported visual loss for the detection of functional diabetic maculopathy and macular edema. DESIGN: Observational case series. PARTICIPANTS: A single eye from each of 104 consecutive patients with diabetes in an academic retina clinic. INTERVENTION: Each eye was screened by Amsler grid, entoptic perimetry, and Humphrey 10-2 threshold visual field testing (HVF 10-2; Humphrey Instruments Inc., San Leandro, CA) in random order. Eyes were then examined clinically. MAIN OUTCOME MEASURES: The presence or absence of new visual decline since the patient's last clinical examination, the presence or absence of central visual field abnormalities using an Amsler grid, entoptic perimetry, HVF 10-2, and the presence or absence of clinically significant macular edema (CSME). RESULTS: The sensitivities and specificities for the detection of central diabetic scotomas as evidenced by HVF 10-2 abnormalities were: subjective impression, 31 of 90 eyes (34.4%) and 11 of 14 eyes (78.6%); Amsler grid, 29 of 90 eyes (32.2%) and 13 of 14 eyes (92.9%); and entoptic perimetry, 58 of 90 eyes (64.4%) and 11 of 14 eyes (78.6%). Entoptic perimetry was statistically more sensitive than both subjective impression (P < 0.001) and Amsler grid (P < 0.001), but the specificities were statistically indistinguishable. The sensitivities and specificities for the detection of CSME were: subjective impression, 6 of 24 eyes (25.0%) and 52 of 80 eyes (65.0%); Amsler grid, 9 of 24 eyes (37.5%) and 59 of 80 eyes (73.8%); and entoptic perimetry, 17 of 24 eyes (70.8%) and 44 of 80 (55.0%) eyes. These results are also statistically significant, with entoptic perimetry being more sensitive and less specific than both subjective impression (P = 0.007 and P = 0.011, respectively) and Amsler grid (P = 0.008 and P < 0.001, respectively) in this subset of patients. CONCLUSIONS: Entoptic perimetry is 87% more sensitive than the subjective impression of visual decline (P < 0.001) and 100% more sensitive than Amsler grid (P < 0.001) for the detection of central scotomas in diabetic patients. For the detection of CSME, entoptic perimetry is 183% more sensitive than subjective impression (P = 0.007) and 89% more sensitive than Amsler grid (P = 0.008). Hence, entoptic perimetry, performed using conventional television, has the potential to be an effective, inexpensive, and widespread adjunct to surveillance examinations for the early detection of diabetic maculopathy.

Brucella bacteraemia: clinical and laboratory observations in 160 patients.

OBJECTIVES: To describe the clinical, serological, and prognostic features of bacteraemic brucellosis in an endemic region. METHODS: Retrospective case series of 160 patients admitted from 1983 to 1995 to a hospital providing secondary and tertiary level medical care in Saudi Arabia. All patients had positive blood cultures for Brucella species, predominantly Brucella melitensis. RESULTS: Bacteraemia was documented in 38% of 545 cases of brucellosis admitted to our institution during the study period. The main clinical syndromes were febrile illness alone (44%) or fever with arthritis (42%). Of 68 isolates that were speciated, 93% were Brucella melitensis. Initial agglutinating antibody titre was > or =1:320 in 96% of the patients. Antimicrobial resistance of B.melitensis isolates was: co-trimoxazole, 29%; rifampicin, 3.5%; streptomycin, 0.6%; and tetracycline, 0.6%. No increase in resistance was noted over the 13-year study period. Commonly used antimicrobial regimens consisted of streptomycin plus tetracycline or rifampicin plus doxycycline given for 6 weeks. Seven patients (5%) had relapse of their symptoms after antimicrobial therapy. Three of these had infective endocarditis with repeated bacteraemia. These patients required aortic valve replacement and recovered after surgery. The remaining four patients responded to a second course of therapy. CONCLUSIONS: Brucella bacteraemia is an acute febrile disease often associated with rheumatologic complaints. Most patients have an agglutinating antibody titre > or =1:320 and respond well to standard chemotherapy regimens with low mortality.

Construction and characterization of a novel recombinant single-chain variable fragment antibody against Western equine encephalitis virus.

A novel recombinant single-chain fragment variable (scFv) antibody against Western equine encephalitis virus (WEE) was constructed and characterized. Using antibody phage display technology, a scFv was generated from the WEE specific hybridoma, 10B5 E7E2. The scFv was fused to a human heavy chain IgG1 constant region (CH1-CH3) and contained an intact 6 His tag and enterokinase recognition site (RS10B5huFc). The RS10B5huFc antibody was expressed in E. coli and purified by affinity chromatography as a 70-kDa protein. The RS10B5huFc antibody was functional in binding to WEE antigen in indirect enzyme-linked immunosorbent assays (ELISAs). Furthermore, the RS10B5huFc antibody was purified in proper conformation and formed multimers. The addition of the human heavy chain to the scFv replaced effector functions of the mouse antibody. The Fc domain was capable of binding to protein G and human complement. The above properties of the RS10B5huFc antibody make it an excellent candidate for immunodetection and immunotherapy studies.

Clinico-diagnostic experience with tuberculous lymphadenitis in Saudi Arabia.

OBJECTIVES: To describe the diagnosis and outcomes of tuberculous lymphadenitis in a low HIV-seroprevalence population at a hospital in Riyadh, Saudi Arabia. METHODS: Retrospective case series of tuberculous lymphadenitis from 1983 to 1998 were examined. RESULTS: There were 99 cases with a median age of 38 years and a female preponderance (female/male ratio of 1.3 : 1). Eighty per cent had cervical involvement and 36% had systemic symptoms. Eighty-nine per cent had their lymphadenopathy for more than 1 month. The diagnostic yield of tuberculin skin testing was 83%, of chest X-ray was 27%, of fine-needle aspiration was 46%, and of excisional lymph node biopsy was 97%. Only one-third of patients received a tuberculin test. There was no significant difference in outcome between 6 and 9 months of chemotherapy, and paradoxical enlargement of nodes occurred in only 6%. CONCLUSIONS: Tuberculous lymphadenitis in our study population was predominantly cervical in location. The diagnostic yield of FNA was lower than that reported in the literature, and might be improved by more frequent tuberculin skin testing, multiple aspirations of lymph nodes, or use of excisional biopsy as the initial diagnostic procedure. Most patients responded well to chemotherapy, with few complications.

Antibiotic resistance. An impending crisis.

The global emergence of antimicrobial resistance has become a pre-eminent concern in medicine and public health. Antimicrobial resistance is of particular concern because the problem is widespread, the causative factors are uncontrolled, and national strategies to address the problem are lacking. The persisting burden of infectious diseases makes elimination of antibiotic use unethical, but dramatic overuse and misuse of antimicrobial agents around the world must be reduced to extend the useful lifetimes of these drugs. Population genetic models suggest that resistance emerges rapidly under the selective pressure of antibiotics, but decays slowly once that pressure is removed. Hence, measures to prevent the emergence of resistance must be implemented urgently. A multiplicity of factors drive antibiotic resistance, and solutions require the collaboration of governmental agencies, the pharmaceutical companies, healthcare providers, and consumers. Leadership in the form of a national steering committee on antimicrobial resistance is needed in the Kingdom of Saudi Arabia to guide collective action to control the threat of antibiotic resistance.

The impact of TennCare on patient satisfaction with care.

OBJECTIVE: To measure the level of satisfaction with care by Medicaid-eligible patients before and after implementation of a mandatory managed care plan known as TennCare. STUDY DESIGN: We used multivariate logit analysis of survey data to calculate the effects of TennCare on patient satisfaction for TennCare patients compared to those on traditional Medicaid, using North Carolina as a control state. PATIENTS AND METHODS: Patients were respondents to a survey conducted in late 1996 and early 1997 who had been admitted to hospitals in 1993 and 1995 for labor/delivery (n = 986), acute myocardial infarction (n = 457), and head trauma (n = 248). Dependent variables were yes/no responses to satisfaction questions for labor/delivery and 5-category ordered responses for adults. RESULTS: We found no statistically significant differences in satisfaction between TennCare and traditional Medicaid for either pediatric or adult hospital patients. Generally, TennCare recipients had satisfaction levels as good or better than traditional Medicaid recipients. For pediatric care, TennCare odds ratios ranged from 1.00 to 2.17, the latter for satisfaction with care received (P = 0.107). For adult care, odds ratios ranged from 0.77 to 1.23, the latter for satisfaction with cost of care (P = 0.547). For many dimensions of care, lower rates of satisfaction were reported for respondents who were uninsured, less educated, and in poor health. For adult care, blacks or Hispanics tended to be less satisfied with some aspects of care. CONCLUSION: TennCare did not reduce patient satisfaction with care among those who were hospitalized.