The impact on clients of a community-based infant mortality reduction program: the National Healthy Start Program Survey of Postpartum Women.

OBJECTIVES: This study assessed the effect of the national Healthy Start Program on its clients. METHODS: We used a cross-sectional survey of a sample from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) rosters of women less than 6 months postpartum who were residents of Healthy Start Program areas. RESULTS: Healthy Start clients revealed higher sociodemographic risk, but not behavioral risk, for adverse pregnancy outcome than other area residents. They did not differ from other residents in receipt of services except for a greater likelihood of receiving case management, using birth control at the time of the interview, and rating their prenatal care more highly. CONCLUSIONS: The Healthy Start Program succeeded in enrolling women at high risk. It had little effect on the immediately concluded pregnancy, but it might influence future outcomes.

Vocal cord dysfunction in patients with exertional dyspnea.

STUDY OBJECTIVES: To evaluate patients for vocal cord dysfunction (VCD) in a military population presenting with symptoms of exertional dyspnea. DESIGN: Cross-sectional, controlled study. SETTING: Pulmonary disease clinic at an army tertiary care center. PATIENTS: Forty military patients with complaints of exertional dyspnea and 12 military asymptomatic control subjects. INTERVENTION: Patients underwent direct visualization of vocal cords with flexible laryngoscopy before and after exercise to evaluate for presence of inspiratory vocal cord adduction. MEASUREMENTS AND RESULTS: Complete evaluation for all patients consisted of spirometry with flow-volume loops, lung volumes, diffusing capacity, and maximum voluntary ventilation at rest; chest radiograph; methacholine bronchoprovocation testing; and a maximal cardiopulmonary exercise test with expiratory gas analysis. Fifteen percent of patients studied prospectively were found to have VCD, whereas all control subjects were negative for VCD. There was minimal difference in pulmonary function testing between VCD-positive and VCD-negative patients, whereas control subjects had higher spirometric values. Twenty percent of VCD-positive patients had abnormal flow-volume loops compared with 14% of patients without VCD, but after methacholine, 60% of VCD-positive patients developed abnormal flow-volume loops. In the VCD-positive group, 60% had a positive methacholine response, but there was less decrease in FEV(1)/FVC ratio compared with either VCD-negative patients or control subjects. CONCLUSIONS: Paradoxical inspiratory vocal cord closure is a frequent occurrence in patients with symptoms of exertional dyspnea and should be strongly considered in their evaluation.

Medicaid managed care and children: an overview.

In recent years, states have increasingly turned to managed care arrangements for financing and delivering health services to Medicaid beneficiaries. In 1996, approximately 40% of all Medicaid recipients were enrolled in some form of managed care. The rapid escalation of managed care in this population has been fueled by states' desire to slow the growth of Medicaid expenditures and by the trend toward managed care enrollment in the private health insurance industry. The effect of managed care on cost containment in the Medicaid program may be limited, however, because 85% to 90% of Medicaid managed care enrollees are women of childbearing age and children, who together account for 69% of Medicaid recipients, but only 26% of program costs. Nonetheless, the increase in managed care enrollment in this population may have a profound impact on health service delivery and health outcomes for U.S. children, approximately 20% of whom received health benefits through the Medicaid program in 1995. In the future, the proportion of Medicaid-eligible children enrolled in managed care will likely increase as a result of recent legislation that relaxed the requirement that states seek federal approval prior to mandating managed care enrollment for Medicaid beneficiaries. More states are relying on fully capitated arrangements as the preferred type of managed care for Medicaid recipients, despite the relative lack of experience many of these plans have in serving this low-income population. Moreover, managed care organizations have few incentives to enroll chronically or disabled children with higher-than-average expected costs. Without mechanisms in place that adequately adjust capitated rates to account for these higher-cost enrollees, managed care organizations may lose money, and children with the greatest health care needs may be underserved. As mandatory managed care enrollment for Medicaid recipients increases nationwide, states should carefully monitor changes in program costs and quality as well as implications for the delivery of pediatric health services and health outcomes.

Young maternal age and depressive symptoms: results from the 1988 National Maternal and Infant Health Survey.

OBJECTIVES: The goal of this study was to provide population-based estimates of the prevalence of depressive symptoms among primiparous US adolescent mothers. METHODS: Data from the live-birth component of the 1988 National Maternal and Infant Health Survey were analyzed. RESULTS: The prevalence of depressive symptoms varied by age and race, from 14% among White adult mothers to 48% among Black mothers 15 to 17 years old. After control for income and marital status, the increased prevalence of depressive symptoms associated with adolescent motherhood was greatly diminished (for 15- to 17-year-old Black women and 18- to 19-year-old White women) or eliminated (for 18- to 19-year-old Black women and 15- to 17-year-old White women). CONCLUSIONS: Adolescent mothers experience high rates of depressive symptoms relative to adult mothers, and mental health and other interventions that alleviate the exacerbating influence of poverty and unmarried status are warranted.

Hearing and the development of language and speech.

The criticality of hearing is discussed in relation to language and speech development in children. The fundamentals for such development, the significant milestones in normal language and speech acquisition, and a delineation of the deleterious effects of significant hearing loss on the development of expressive and receptive oral communication are presented.

Balancing our lives: a study of the married couple's experience with breast cancer recurrence.

PURPOSE/OBJECTIVES: To examine the married couple's experience with breast cancer recurrence from each partner's own perspective, to describe their mood and martial quality, and to develop an initial explanatory theory of the couple's lived experience with breast cancer recurrence. DESIGN: Descriptive, qualitative. SETTING: Homes of married couples in the Pacific Northwestern United States. SAMPLES: 15 married couples comprised of women diagnosed with recurrent breast cancer and their husbands. The median length of time since recurrence was 10 months. METHODS: Structured interviews were conducted in the homes of married couples that met eligibility criteria using an open-ended interview schedule, the Marital Dyad Interview, and two standardized questionnaires-the Spanier Dyadic Adjustment Scale and the Center for Epidemiological Studies Depression Scale. MAIN RESEARCH VARIABLES: Lived experience of couples to breast cancer recurrence, depressed mood, and marital adjustment. FINDINGS: BALANCING OUR LIVES was the core category that explained how the couples lived with the breast cancer recurrence. Couples actively worked to balance their lives by keeping the breast cancer a background, not a foreground, issue. Although couples talked about managing the daily realities of the woman's breast cancer, not dwelling on the cancer and moving ahead and healing themselves was most important. Balancing Our Lives involved the couples in four major processes: managing the woman's everyday illness, surviving, healing, and preparing for death. Concurrently, one or both members of 60% of the couples scored outside the normative range on either depressed mood or marital adjustment. CONCLUSIONS: The couples' ways of managing the breast cancer recurrence through balancing their lives may be facilitating their behavioral functioning but may not be enhancing their mood or marital quality. IMPLICATIONS FOR NURSING PRACTICE: The couples' management of recurrence may benefit from additional strategies, including helping them work through sad thoughts or feelings instead of avoiding them; recognizing and supporting each other's views, even when their views differ; and helping them to learn ways to express sad thoughts and feelings without overly dwelling on them.

The effectiveness of community health nursing interventions: a literature review.

As the devastating impact of many public health problems becomes more evident nationwide, a need exists for effective programs aimed at community-oriented health promotion. Escalating health care costs, however, severely limit available health care resources, threatening the demise of many public health efforts. During this time of imminent reform in our national health care system, it is imperative for community health nurses to elicit support by demonstrating the efficacy of their interventions (Oda & Boyd, 1987). This article describes services provided by community health nurses and documents the effectiveness of these interventions based on available literature. The programs reviewed represent community health nursing strategies developed in response to the needs of high-risk families, geographic communities, and vulnerable population groups. Both descriptive analyses and outcome-evaluation studies are used to support the effectiveness of home-based and community-centered community health nursing interventions. Recommendations eliciting support for community health nursing practice from legislators, policy makers, practice agencies, professional organizations, educators, and research institutions are included.

Ratings of vocal pleasantness and the aging process.

In response to the questions raised at the outset, the following summary statements can be made: (1) Listeners were reliable in making pleasantness judgments. All listening groups were reliable, but the two older listening age-groups had the highest correlation coefficients. (2) Speakers were judged as less pleasant as their age levels increased. (3) Young listeners made judgments nearer the unpleasant end of the scale than did the older listeners. (4) Male speakers were judged as more pleasant than were female speakers. (5) Female listeners rated speakers as being more pleasant than did the male listeners.

Amino Acid Metabolism of Lemna minor L. : II. Responses to Chlorsulfuron.

Chlorsulfuron, an inhibitor of acetolactate synthase (EC 4.1.3.18) (TB Ray 1984 Plant Physiol 75: 827-831), markedly inhibited the growth of Lemna minor at concentrations of 10(-8) molar and above, but had no inhibitory effects on growth at 10(-9) molar. At growth inhibitory concentrations, chlorsulfuron caused a pronounced increase in total free amino acid levels within 24 hours. Valine, leucine, and isoleucine, however, became smaller percentages of the total free amino acid pool as the concentration of chlorsulfuron was increased. At concentrations of chlorsulfuron of 10(-8) molar and above, a new amino acid was accumulated in the free pool. This amino acid was identified as alpha-amino-n-butyrate by chemical ionization and electron impact gas chromatography-mass spectrometry. The amount of alpha-amino-n-butyrate increased from undetectable levels in untreated plants, to as high as 840 nanomoles per gram fresh weight (2.44% of the total free pool) in plants treated with 10(-4) molar chlorsulfuron for 24 hours. The accumulation of this amino acid was completely inhibited by methionine sulfoximine. Chlorsulfuron did not inhibit the methionine sulfoximine induced accumulations of valine, leucine, and isoleucine, supporting the idea that the accumulation of the branched-chain amino acids in methionine sulfoximine treated plants is the result of protein turnover rather than enhanced synthesis. Protein turnover may be primarily responsible for the failure to achieve complete depletion of valine, leucine, and isoleucine even at concentrations of chlorsulfuron some 10(4) times greater than that required to inhibit growth. Tracer studies with (15)N demonstrate that chlorsulfuron inhibits the incorporation of (15)N into valine, leucine, and isoleucine. The alpha-amino-n-butyrate accumulated in the presence of chlorsulfuron and [(15)N]H(4) (+) was heavily labeled with (15)N at early time points and appeared to be derived by transamination from a rapidly labeled amino acid such as glutamate or alanine. We propose that chlorsulfuron inhibition of acetolactate synthase may lead to accumulation of 2-oxobutyrate in the isoleucine branch of the pathway, and transamination of 2-oxobutyrate to alpha-amino-n-butyrate by a constitutive transaminase utilizing either glutamate or alanine as alpha-amino-N donors.

Amino Acid Metabolism of Lemna minor L. : I. Responses to Methionine Sulfoximine.

When Lemna minor L. is supplied with the potent inhibitor of glutamine synthetase, methionine sulfoximine, rapid changes in free amino acid levels occur. Glutamine, glutamate, asparagine, aspartate, alanine, and serine levels decline concomitantly with ammonia accumulation. However, not all free amino acid pools deplete in response to this inhibitor. Several free amino acids including proline, valine, leucine, isoleucine, threonine, lysine, phenylalanine, tyrosine, histidine, and methionine exhibit severalfold accumulations within 24 hours of methionine sulfoximine treatment. To investigate whether these latter amino acid accumulations result from de novo synthesis via a methionine sulfoximine insensitive pathway of ammonia assimilation (e.g. glutamate dehydrogenase) or from protein turnover, fronds of Lemna minor were prelabeled with [(15)N]H(4) (+) prior to supplying the inhibitor. Analyses of the (15)N abundance of free amino acids suggest that protein turnover is the major source of these methionine sulfoximine induced amino acid accumulations. Thus, the pools of valine, leucine, isoleucine, proline, and threonine accumulated in response to the inhibitor in the presence of [(15)N]H(4) (+), are (14)N enriched and are not apparently derived from (15)N-labeled precursors. To account for the selective accumulation of amino acids, such as valine, leucine, isoleucine, proline, and threonine, it is necessary to envisage that these free amino acids are relatively poorly catabolized in vivo. The amino acids which deplete in response to methionine sulfoximine (i.e. glutamate, glutamine, alanine, aspartate, asparagine, and serine) are all presumably rapidly catabolized to ammonia, either in the photorespiratory pathway or by alternative routes.

Clues to aural discrimination.

Five measures of the items of the Multiple-Choice Intelligibility Test were obtained: apparent aural similarity of the four words available to a listener on hearing a stimulus, interconsonantal differences among the prevocalic portions of these words, phonemic discrepancies among these words, distinctive feature differences among these words, and the pooled discrimination score of the four words that were available to the responder on hearing the stimulus. The last score was made the target in a multiple correlation problem, and the relative contribution, combined and separately, of the four remaining measures to the target measure was determined. These four measures accounted for approximately 45% of the variance among the scores of discrimination. The strongest contributors were apparent aural similarity of the available responses and the phonemic discrepancy among the available responses.

The effects of duration, frequency, and loudness upon the reproduction of temporal intervals.

Subjects (five normal hearing graduate students in the Department of Audiology) were asked to reproduce temporal intervals of 1, 3, 5, 7, and 9 sec. The intervals were filled with pure tones at frequencies of 250, 500, 1000, 2000, and 4000 Hz and at loudness levels of 40, 50, 60, 70, and 80 phons. The reproductions were transformed into the ratio DT/T, where DT represents the difference-time between the stimulus duration and the duration of the reproduction, and T represents the stimulus duration. It was found that neither frequency nor loudness had any significant effect upon the ability to reproduce the durations. The only significant variable was duration. There were no significant interactions among the variables. On the average, the durations of 1 and 3 sec were overestimated and the durations of 7 and 9 sec were overestimated. The duration of 5 sec was neither overestimated nor underestimated, the indifference point falling at 4.90 sec.