Access and service use by children with autism spectrum disorders in Medicaid Managed Care.

Although Medicaid is the largest public payer of behavioral health services, information on access and utilization of services is lacking, and no data on the frequency of service use or types of services provided for children with autism spectrum disorders (ASDs) are available. As states move toward managed care approaches for their Medicaid program, services information is critical. Behavioral health service data for children with autism spectrum disorders were collected from a state Medicaid Managed Care (MMC) program and analyzed from fiscal years 1995 through 2000. Findings revealed that the number of children who received services over time increased significantly; however, the rate of service use was only one tenth of what should be expected based on prevalence rates. The mean number of service days provided per child decreased significantly, about 40%, and the most prevalent forms of treatment changed. Day treatment vanished and medication and case management increased disproportionately to the number of children served. Explanations and implications of the findings are presented as well as recommendations for future research.

Oral corticosteroid use among children in TennCare.

BACKGROUND: Lack of information about medication effects and use in children is a long-standing and troublesome policy issue. Documenting patterns of use for medications with potential for suboptimal use and adverse effects, such as oral corticosteroids, would be useful. OBJECTIVE: To describe the use of oral corticosteroids among children enrolled in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured individuals. DESIGN: A retrospective cohort study. DRUG EXPOSURE: Children enrolled in TennCare who had prescriptions filled in their name for oral corticosteroids during 1998 were identified. Descriptive information included age, race, sex, and county of residence. We identified possible indications for corticosteroid use for new users by searching encounter files for encounters temporally related to the index prescription. Subsequent use of corticosteroids was measured in the 365 days after the index prescription. RESULTS: Of 400 724 children continuously enrolled in TennCare during the study period, 29 362 (7327 per 100 000) children had a prescription filled for an oral corticosteroid. Steroid prescription filling was more common among young children and male children and less common among black children. Children in rural counties had oral corticosteroid prescriptions filled at a higher rate than children residing in urban counties. Nearly 75% of corticosteroid users filled only 1 prescription during the study period; 1319 children filled 4 or more prescriptions. Asthma was the most common indication for oral corticosteroid use (16%), whereas 1 in 5 users (22%) had an unknown indication for oral corticosteroid use. CONCLUSIONS: A large number of children enrolled in TennCare had a prescription for oral corticosteroids filled in 1998. Further population-based studies describing the development of adverse effects in users of corticosteroids would be important.

High performance DNA sequencing, and the detection of mutations and polymorphisms, on the Clipper sequencer.

The Visible Genetics Clipper sequencer is a new platform for automated DNA sequencing which employs disposable MicroCel cassettes and 50 microm thick polyacrylamide gels. Two DNA ladders can be analyzed simultaneously in each of 16 lanes on a gel, after labeling with far-red absorbing dyes such as Cy5 and Cy5.5. This allows a simultaneous bidirectional sequencing of four templates. We have evaluated the Clipper sequencer, by cycle-sequencing of an M13 single-stranded DNA standard, and by coupled amplification and sequencing (CLIP) of reverse-transcribed human immunodeficiency virus (HIV-1) RNA standards and clinical patient samples. (i) Limitations of instrument. We have examined basic instrument parameters such as detector stability, background, digital sampling rate, and gain. With proper usage, the optical and electronic subsystems of the Clipper sequencer do not limit the data collection or sequence-determination processes. (ii) Limitations of gel performance. We have also examined the physics of DNA band separation on 50 microm thick MicroCel gels. We routinely obtain well-resolved sequence which can be base-called with 98.5% accuracy to position approximately 450 on an 11 cm gel, and to position approximately 900 on a 25 cm gel. Resolution on 5 and 11 cm gels ultimately is limited by a sharp decrease in spacing between adjacent bands, in the biased reptation separation regime. Fick's (thermal) diffusion appears to be of minor importance on 6 cm or 11 cm gels, but becomes an additional resolution-limiting factor on 25 cm gels. (iii) Limitations of enzymology. Template quality, primer nesting, choice of DNA polymerase, and choice between dye primers and dye terminators are key determinants of the ability to detect mutations and polymorphisms on the Clipper sequencer, as on other DNA sequencers. When CLIP is used with dye-labeled primers and a DNA polymerase of the F667Y, delta(5'--> 3' exo) class, we can routinely detect single-nucleotide mutations and polymorphisms over the 0.35-0.65 heterozygosity range. We present an example of detecting therapeutically relevant mutations in a clinical HIV-1 RNA isolate.

Successful self-management of severe bulimia: a case study.

A young woman with a nine-year history of bingeing and purging was given instruction in behavioral principles. She then designed and carried out a program that included paced eating of pre-planned meals, following by differential reinforcement of non-purging behaviors, which featured high frequency of reinforcement early in training. Inter-meal "binge-feelings" were treated by reinforcing abstentions. A graded system of contingent exercise also was employed for purging behaviors. Episodes decreased to a low level after one month and were completely absent nine months later. The amelioration of this problem resulted in progress being made for the first time with her emotional problems that were being treated elsewhere by psychodynamic psychotherapy.

Motor activity and sleep duration as a function of age in healthy men.

Patient activity monitors (PAM's) and self-report diaries were employed to examine wrist movements over a 9 day period in 43 healthy men aged 21 to 83 years, in their natural home and work environments. The mean sleep duration (from PAM) equaled 7.29 +/- 0.8 (S.D.) hr compared to 7.84 +/- 0.62 hr as estimated from the daily diaries. Neither parameter was correlated significantly with age (p greater than 0.05). Net activity counts per 24 hr day declined significantly with age (p less than 0.05), but the effect of age was small and accounted for only 15% of the variance. When the data from each age group were averaged into mean 24 hr days, it was found that: (1) the greatest reductions in the older subjects' activity occurred during evening hours; (2) differences between old and young subjects were more profound on weekends than on weekdays; and (3) only the young subjects' activity profiles differed between weekdays and weekends, as they rose from bed later on weekends. The results indicate that 24 hr activity can be quantified and characterized in natural work and home environments, in relation to diary information. Only small age differences occur in overall 24 hr activity in rigorously screened healthy men.

Evaluation of zimeldine in Alzheimer's disease. Cognitive and biochemical measures.

Neuropsychological and neurochemical effects of zimeldine, a relatively specific serotonin reuptake blocker, were examined in four patients with clinically diagnosed Alzheimer's disease, in a double-blind, placebo-controlled, crossover study. Individualized doses of zimeldine were administered to achieve target plasma zimeldine concentrations of approximately 50 (low) to 100 (high) ng/mL. Overall, there was no significant effect of zimeldine on memory or reaction time measures as compared with placebo. The drug significantly reduced (by up to 38%) 5-hydroxyindoleacetic acid concentrations in the cereobrospinal fluid and almost abolished (90% reduction) platelet serotonin uptake. Cerebrospinal fluid concentrations of 3-methoxy-4-hydroxy-phenylglycol, a major metabolite of norepinephrine, and homovanillic acid, the major metabolite of dopamine, were not altered. Our findings indicate that alterations in central and peripheral serotoninergic function by a serotonin reuptake blocker (zimeldine) are unaccompanied by measurable changes in memory and/or reaction time in patients presumed to have Alzheimer's disease.

Cerebral glucose utilization, as measured with positron emission tomography in 21 resting healthy men between the ages of 21 and 83 years.

Positron emission tomography (PET) scanning with 18F-2-deoxy-D-glucose was employed to examine hemispheric and regional rates of cerebral glucose utilization in 21 resting healthy men between the ages of 21 and 83 years. The eyes of the subjects were covered and the external auditory canals were plugged with cotton in the 45 minutes following injection of tracer. Mean hemispheric cerebral metabolic rates for glucose (CMRglc) averaged 4.3 to 4.4 mg x 100 g-1 X min-1, and mean hemispheric grey matter glucose utilization, (CMRglc)grey, averaged 5.2 to 5.3 mg x 100 g-1 X min-1. Neither parameter was correlated significantly with age, nor were their right/left ratios correlated with age (P greater than 0.05). The mean ratios, furthermore, did not differ significantly from 1. Regional cerebral metabolic rates for glucose, rCMRglc, at each of 31 identified midline and bilateral structures also were not correlated significantly with age. Mean rCMRglc ranged from 2.6 mg X 100 g-1 X min-1 at the centrum semiovale to 6.2 mg . 100 g-1 X min-1 at the precentral gyrus of the frontal lobe and precuneus of the parietal lobe. The results indicate that the cerebral metabolic rate for glucose is not correlated with age in healthy men.

Discriminated instrumental learning by an acute encéphale isolé preparation.

Rats were prepared and maintained with high cervical transections in order to study learning in an intact brain that is isolated from uncontrolled sensory input and immobilized, allowing ready access to central physiological mechanisms. Stimulation electrodes were aimed at loci associated with response reinforcing processes. A response sensor was placed in the mouth to record both learned and evoked biting. All experimental subjects were trained successfully to discriminate the presence of an exteroceptive stimulus that indicated availability of the brain stimulation for biting. An intact control subject performed similarly in a lever pressing situation for brain stimulation. Biting also was evoked in both experimental and control subjects following removal of reinforcers, in a relation like that previously demonstrated between withdrawal of reinforcers and attack. The value of the experimental procedure in the study of the neural bases of learning and of the interactions between learned and inherent response processes is discussed.

Suppression of shock elicited target biting by analgesic midbrain stimulation.

Rats with chronic electrodes in or near the central gray (PVG) of the midbrain were tested with a tail pinch to determine analgesic brain stimulation parameters. Then blocks of tail shock, adjusted to a level that produced consistent biting on an inanimate target, were alternated with blocks of tail shock preceded by PVG stimulation. Biting following the tail shock was reduced or eliminated when the brain stimulation preceded the shock. It was concluded that stimulation in the PVG region reduces target biting produced by nociceptive stimulation, probably via an analgesic effect. Also, no biting was associated with brain stimulation, indicating that the bite suppression function is separate from the attack producing function of other central gray areas.

Effects of long-term shock and associated stimuli on aggressive and manual responses.

Squirrel monkeys were exposed to response-independent, fixed-frequency shock that produced biting attack upon a pneumatic hose. Attacks decreased within and across sessions at low intensities and high frequencies of shock, but increased within and across sessions at higher intensities and lower shock frequencies. Stimuli paired with shock, when presented alone, came to produce biting, and stimuli correlated with shock parameters that produced increases in responding within sessions produced similar increases when presented alone. Further experiments showed that continuing exposure to shock also produced lever pressing or chain pulling, with longer shock exposure again producing higher response rates. Whereas biting generally decreased throughout the intershock interval, manual responding generally increased as shock time approached, but immediately before shock was often suppressed. Following shock, biting attack predominated over manual behavior. The results suggest a possible explanation for the extreme resistance of avoidance behavior to extinction, and may also partially explain the persistence of responding during schedules of response-produced shock. Relationships of the present findings to naturalistic observations of relations between fleeing, freezing, and fighting performances are discussed.

Effects of shock intensity and duration on the frequency of biting attack by squirrel monkeys.

Squirrel monkeys were periodically exposed to brief tail-shocks in the presence of a rubber tube connected to a pneumatic switch. Biting attack upon this tube was found to be a decreasing function of time since shock delivery and a direct function of shock intensity and duration. These results parallel findings in investigations employing more "naturalistic" social situations, indicating that attack against the inanimate and animate environment is a direct function of the intensity of an aversive stimulus. The results also demonstrate that frequency of biting attack as a datum is sensitive to several experimental manipulations.