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A pilot study was performed to evaluate the safety and serological responses after co-administration of two multivalent inactivated vaccines to pregnant cattle. One vaccine was directed against bovine respiratory disease (BRD) and contained antigens of bovine respiratory syncytial virus (BRSV), parainfluenza 3 virus (PI3) and Mannheimia haemolytica (Mh). The second vaccine targeted neonatal calf diarrhoea (NCD) and was composed of inactivated antigens of bovine rotavirus (BRV), bovine coronavirus (BCV) and E. coli. The use of these combinations have been used more and more by veterinary practitioners as there exist some clear evidence that both vaccines improves the passive protection via the colostrum for the relevant pathogens. However, up until now, no safety or efficacy data has been available concerning such co-administrations. The safety of both vaccines and the serological responses to the BRD vaccine has been evaluated when used at the same time, but without mixing and compared to the responses to the administration of each vaccine independently. There was no evidence of any negative effect on calving or calf health in any of the vaccinated animals. The antibody levels against BRSV and Mh in the sera of the calves from cows vaccinated with both vaccines were not significantly different from the levels in the sera of calves vaccinated with the BRD vaccine alone. The results from this pilot study demonstrated that the co-administration of the two multivalent inactivated vaccines had no detrimental effect on the safety or serological responses to the BRD vaccine compared to the independent use of the vaccines.

A letter to the editor is presented in response to the Hartmann's procedure in the April 1993 issue.

Atypical porcine pestivirus (APPV) is a novel member of the Pestivirus genus detected in association with congenital tremor (CT) type A-II outbreaks and from apparently healthy pigs, both as singular infection and as part of multi-pathogen infections. 'Classical' pestiviruses are known to cause immunosuppression of their host, which can increase susceptibility to secondary infections, severely impacting health, welfare, and production. To investigate APPV's effect on the host's immune system and characterise disease outcomes, 12 piglets from a natural APPV CT type A-II outbreak were experimentally infected with porcine reproductive and respiratory syndrome virus (PRRSV), a significant porcine pathogen. Rectal temperatures indicating febrile responses, viremia and viral-specific humoral and cellular responses were assessed throughout the study. Pathological assessment of the lungs and APPV-PRRSV co-localisation within the lungs was performed at necropsy. Viral co-localisation and pathological assessment of the lungs (Immunohistochemistry, BaseScope in situ hybridisation) were performed post-mortem. APPV status did not impact virological or immunological differences in PRRSV-infected groups. However, significantly higher rectal temperatures were observed in the APPV +ve /PRRSV +ve group over four days, indicating APPV increased the febrile response. Significant differences in the lung consolidation of the apical and intermediate lobes were also present, suggesting that APPV co-infection may augment lung pathology., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The health and productivity of dairy goats continue to be impacted by gastrointestinal nematodes (GIN) and lungworms (LW). Eprinomectin (EPN) is frequently selected for treatment because it is generally effective and does not require a milk withdrawal period. However, some factors, such as lactation, can have an impact on EPN pharmacokinetics and potentially its efficacy. To evaluate whether this can alter the efficacy of Eprecis ® 2%, an eprinomectin injectable solution, a study was performed in lactating goats using the dose currently registered in cattle, sheep and goats (0.2 mg/kg)., Methods: This study was a blinded, randomized, controlled trial performed according to the VICH guidelines. Eighteen (18) worm-free lactating goats were included and experimentally challenged on day 28 with a mixed culture of infective gastrointestinal and lung nematode larvae (Haemonchus contortus, Trichostrongylus colubriformis, Teladorsagia circumcincta, Dictyocaulus filaria). At D-1, fecal samples were collected to confirm patent infection in all animals. On D0, the goats were randomly allocated into two groups of nine goats; group 1 was treated with Eprecis ® 2% at 0.2 mg/kg BW by subcutaneous injection, while group 2 remained untreated. Fecal samples for egg counts were collected from all animals on days 3, 5, 7, 9, 11 and 14. On D14, all goats were killed, and the abomasum, small intestine and lungs were removed, processed and subsampled to record the number and species of worms., Results: The treatment was well tolerated. After treatment, the arithmetic mean FEC decreased in the treated group and remained < 5 EPG until the end of the study, while the arithmetic mean FEC in the control group remained > 849.0 EPG. At D14, goats in the treated group had very limited or zero total worm counts, whereas all animals from the control group had a high worm burden. The measured efficacy was 100.0% against H. contortus and T. colubriformis, 99.9% against T. circumcincta and 98.0% against D. filaria., Conclusions: Eprinomectin (Eprecis ® , 20 mg/ml), administered at the label dose (0.2 mg/kg), is highly effective against gastrointestinal nematodes and lungworms in lactating goats., (© 2024. The Author(s).)

Background: The effect of a water-soluble formulation of tylvalosin (Aivlosin® 625 mg/g granules) on disease caused by porcine reproductive and respiratory syndrome virus (PRRSV) and Mycoplasma hyopneumoniae (Mhyop) was investigated in two animal studies. In a PRRSV challenge model in pregnant sows (n = 18), six sows received water medicated at target dose of 5 mg tylvalosin/kg body weight/day from 3 days prior to challenge until the end of gestation. Six sows were left untreated, with a third group remaining untreated and unchallenged. Sows were challenged with PRRSV-2 at approximately 85 days of gestation. Cytokines, viremia, viral shedding, sow reproductive parameters and piglet performance to weaning were evaluated. In a dual infection study (n = 16), piglets were challenged with Mhyop on days 0, 1 and 2, and with PRRSV-1 on day 14 and euthanized on day 24. From day 10 to 20, eight piglets received water medicated at target dose of 20 mg tylvalosin/kg body weight/day and eight piglets were left untreated. Cytokines, viremia, bacteriology and lung lesions were evaluated., Results: In the PRRSV challenge study in pregnant sows, tylvalosin significantly reduced the levels of serum IL-8 (P < 0.001), IL-12 (P = 0.032), TNFα (P < 0.001) and GM-CSF (P = 0.001). IL-8 (P = 0.100) tended to be lower in uterus of tylvalosin sows. All piglets from tylvalosin sows surviving to weaning were PRRSV negative in faecal swabs at weaning compared to 33.3% PRRSV positive piglets from untreated sows (P = 0.08). In the dual challenge study in piglet, tylvalosin reduced serum IL1β, IL-4, IL-6, IL-8, IL-10, IL-12, IL-1α, IL-13, IL-17A, IL-18, GM-CSF, TGFβ1, TNFα, CCL3L1, MIG, PEPCAM-1 (P < 0.001) and increased serum IFNα, IL-1ra and MIP-1b (P < 0.001). In the lungs, tylvalosin reduced IL-8, IL-10 and IL-12 compared to untreated pigs (P < 0.001) and tended to reduce TNFα (P = 0.082). Lung lavage samples from all tylvalosin treated piglets were negative for Mhyop (0 cfu/mL) compared to the untreated piglets which had mean Mhyop counts of 2.68 × 10 4  cfu/mL (P = 0.023)., Conclusion: Overall, tylvalosin reduced both local and systemic proinflammatory cytokines after challenge with respiratory pathogens in sows and in piglets. Tylvalosin was effective in reducing Mhyop recovery from the lungs and may reduce virus shedding in piglets following transplacental PRRSV infection in sows., (© 2023. The Author(s).)

Advanced imaging and DNA sequencing technologies now enable the diverse biology community to routinely generate and analyze terabytes of high resolution biological data. The community is rapidly heading toward the petascale in single investigator laboratory settings. As evidence, the single NCBI SRA central DNA sequence repository contains over 45 petabytes of biological data. Given the geometric growth of this and other genomics repositories, an exabyte of mineable biological data is imminent. The challenges of effectively utilizing these datasets are enormous as they are not only large in the size but also stored in geographically distributed repositories in various repositories such as National Center for Biotechnology Information (NCBI), DNA Data Bank of Japan (DDBJ), European Bioinformatics Institute (EBI), and NASA's GeneLab. In this work, we first systematically point out the data-management challenges of the genomics community. We then introduce Named Data Networking (NDN), a novel but well-researched Internet architecture, is capable of solving these challenges at the network layer. NDN performs all operations such as forwarding requests to data sources, content discovery, access, and retrieval using content names (that are similar to traditional filenames or filepaths) and eliminates the need for a location layer (the IP address) for data management. Utilizing NDN for genomics workflows simplifies data discovery, speeds up data retrieval using in-network caching of popular datasets, and allows the community to create infrastructure that supports operations such as creating federation of content repositories, retrieval from multiple sources, remote data subsetting, and others. Named based operations also streamlines deployment and integration of workflows with various cloud platforms. Our contributions in this work are as follows 1) we enumerate the cyberinfrastructure challenges of the genomics community that NDN can alleviate, and 2) we describe our efforts in applying NDN for a contemporary genomics workflow (GEMmaker) and quantify the improvements. The preliminary evaluation shows a sixfold speed up in data insertion into the workflow. 3) As a pilot, we have used an NDN naming scheme (agreed upon by the community and discussed in Section 4) to publish data from broadly used data repositories including the NCBI SRA. We have loaded the NDN testbed with these pre-processed genomes that can be accessed over NDN and used by anyone interested in those datasets. Finally, we discuss our continued effort in integrating NDN with cloud computing platforms, such as the Pacific Research Platform (PRP). The reader should note that the goal of this paper is to introduce NDN to the genomics community and discuss NDN's properties that can benefit the genomics community. We do not present an extensive performance evaluation of NDN-we are working on extending and evaluating our pilot deployment and will present systematic results in a future work., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Ogle, Reddick, Mcknight, Biggs, Pauly, Ficklin, Feltus and Shannigrahi.)

Introduction: Insulin-like peptide 5 (INSL5) is a peptide hormone with proposed actions in glucose homeostasis and appetite regulation via its cognate receptor, relaxin family peptide receptor 4 (RXFP4). Here, we look for evidence for their involvement in the immune system using a mouse model., Methods: In silico analyses: we queried public databases for evidence of expression of INSL5-RXFP4 in immune system tissues/cells (NCBI's SRA and GeoProfiles) and disorders (EMBO-EBI) and performed phylogenetic footprinting to look for evidence that they are regulated by immune-associated transcription factors (TFs). Experimental analyses: We characterized the expression and correlation of INSL5/RXFP4 and other immune system markers in central and peripheral immune organs from C57/bl6 mice in seven cohorts. We tested whether fluctuations in circulating INSL5 induce an immune response, by injecting mice with 30 μg/kg of INSL5 peptide in the peritoneum, and examining levels of immune markers and metabolic peptides in plasma. Lastly, we quantified the expression of Rxfp4 in T-cells, dendritic cells and cell lines derived from human and mouse and tested the hypothesis that co-incubation of ANA-1 cells in INSL5 and LPS alters cytokine expression., Results: We find Insl5 expression only in thymus (in addition to colon) where its expression was highly correlated with Il-7 , a marker of thymocyte development. This result is consistent with our in silico findings that Insl5 is highly expressed in thymic DP, DN thymocytes and cortical TEC's, and with evidence that it is regulated by thymocyte-associated TF's. We find Rxfp4 expression in all immune organs, and moderately high levels in DCs, particularly splenic DCs, and evidence that it is regulated by immune-associated TF's, such as STAT's and GATA. Systemic effects : We observed significantly elevated concentrations of blood GLP-1, GIP, GCG and PYY following intraperitoneal injection of INSL5, and significantly altered expression of cytokines IL-5, IL-7, M-CSF, IL-15, IL-27 and MIP-2. Immune cell effects : Incubation of ANA-1 cells with INSL5 impeded cell growth and led to a transient elevation of IL-15 and sustained reduction in IL-1β, IL-6 and TNFα., Conclusion: We propose that INSL5-RXFP4 play a novel role in both central and peripheral immune cell signaling., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Vahkal, Yegorov, Onyilagha, Donner, Reddick, Shrivastav, Uzonna and Good.)

This study was designed to evaluate the efficacy of a new florfenicol/meloxicam combination (FMC) in calves with bovine respiratory disease. A total of 90 young calves were challenged via intratracheal deposition of 10 8  colony-forming units of Mannheimia haemolytica Data for 84 calves demonstrating a rectal temperature (RT) above 39.5°C and a combined total clinical score (TCS) greater than or equal to 3 were included. Calves were then randomly allocated to one of the three study groups (FMC; florfenicol/flunixin combination (FFC); or saline) and promptly treated. RT and TCS of calves treated with an FMC or FFC were consistently lower than RT and TCS of calves belonging to the control group (P<0.001). Moreover, at the end of the study, a high clinical cure rate was observed in calves treated with FMC (100 per cent) or FFC (96.6 per cent) whereas cure was limited for calves receiving saline (29.6 per cent). Interestingly, calves treated with FMC were cured without relapse more rapidly compared with calves treated with FFC (HR=1.76, P<0.05) and with a lower percentage of clinical relapse due to fever (P=0.05). These results underline the high efficacy of the FMC and are in line with the pharmacokinetic properties of florfenicol and meloxicam., Competing Interests: Competing interests: DA, ACV and JFC are employees of Ceva Santé Animale., (© British Veterinary Association 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

The objective of this negative controlled, blinded, randomised, parallel group study was to compare the efficacy of two injectable macrolide antimicrobials, tulathromycin and tildipirosin, administered by single subcutaneous injection at dose rates of 2.5 and 4.0 mg kg -1 bodyweight, respectively, in the treatment of an experimentally induced Mycoplasma bovis infection in calves. A total of 238 M. bovis- negative calves were challenged on three consecutive days with M. bovis by endobronchial deposition. Post-challenge, a total of 126 animals fulfilled the inclusion criteria and were randomly allocated to three treatment groups: tulathromycin, tildipirosin and saline. Clinical observations for signs of respiratory disease and injection site assessments were conducted daily for 14 days post-treatment. The animals were then killed, the lungs were examined for evidence of lesions, and samples collected for bacterial isolation. Calves treated with tulathromycin had a lower percentage of lung with lesions ( P  =   0.0079), lower mortality ( P  =   0.0477), fewer days with depressed demeanour ( P  =   0.0486) and higher body weight ( P  =   0.0112) than calves administered tildipirosin.

Communities will rely on open points of dispensing (PODs) for mass dispensing of medical countermeasures following a bioterrorism attack or a pandemic. US Cities Readiness Initiative (CRI) open POD preparedness is assessed using the Technical Assistance Review (TAR) but focuses on oral prophylaxis dispensing; mass vaccination readiness is not well measured. Non-CRI preparedness had not been studied. In 2013 an online questionnaire was sent to all 456 CRIs and a random sample of 500 non-CRIs to measure open POD preparedness and exercise participation. Hierarchical linear regression was used to describe factors associated with higher POD preparedness and exercise participation scores. In total, 257 subjects participated, for a 41% response rate. Almost all open PODs have existing written plans and/or a layout for each site (93.4%, n=240, and 87.0%, n=220). Only half (46.7%, n=120) have an alternative dispensing modality in place, and even fewer (42.6%, n=104) report having adequate staffing. Determinants of open POD preparedness were perceived preparedness, participation in more POD exercises, and more closed POD coverage. Most jurisdictions conducted a full-scale exercise and a staff notification drill (83.7%, n=215 for both). Fewer than half (40.5%, n=104) have conducted a vaccination clinic exercise. Determinants of increased POD exercises were perceived preparedness, years of work experience, community type (nontribal), and larger population. Because successful open POD deployment is critical, jurisdictions need to plan for mass vaccination, use of alternative dispensing modalities, and recruitment strategies to increase POD staffing.

The Centers for Disease Control and Prevention recommends using open points of dispensing (PODs) and alternative modalities, such as closed PODs, for mass dispensing of medical countermeasures. However, closed POD existence has not been assessed. In 2013 we sent an online questionnaire to US Cities Readiness Initiative (CRI) and non-CRI public health disaster planners. Chi-square tests were used to determine differences between CRIs and non-CRIs when comparing having at least 1 closed POD, and to compare having a closed POD and perceived mass dispensing preparedness. A total of 301 disaster planners participated. Almost all (89.3%, n=218) jurisdictions have considered establishing a closed POD, and three-quarters (74.2%, n=181) currently have at least one. CRIs were more likely than non-CRIs to have a closed POD (85.0% vs 58.5%, X(2)=21.3, p<.001). Those with 1 or more closed PODs were more likely to believe their jurisdiction could distribute medical countermeasures within 48 hours compared to those without a closed POD (78.5% vs 21.5%; X(2)=10.8, p=.001). Half had a written plan and/or written standing orders (59.1% and 52.5%, respectively). Almost half (42%, n=72) have done no preevent training for POD staff in the past 2 years; almost 20% (18%, n=32) do not plan to offer any just-in-time training. Nearly 40% (n=70) have conducted no exercises in the past year. Closed PODs contribute to community preparedness; their establishment should be followed by development of written plans, worker training, and exercises.

Background: Only limited data are available on businesses' experiences related to the 2009 H1N1 pandemic in terms of interventions implemented, staffing shortages, employees working while ill, and H1N1 vaccination policy., Methods: A questionnaire was administered to human resource professionals during May-July 2011 to assess US businesses' experiences related to the 2009 pandemic. Logistic regressions were used to describe factors associated with providing H1N1 and respiratory hygiene training and offering H1N1 vaccine to staff. Linear regression was used to describe factors associated with higher infection prevention intervention scores (ie, number of interventions implemented)., Results: In all, 471 human resource professionals participated. Most (85.1%, n = 401) did not work while ill. Twelve percent (n = 57) reported staffing shortages, 2.1% (n = 10) needed to hire temporary staff, and fewer than 1% (0.8%, n = 4) reduced workload or closed during the pandemic. From logistic and linear regressions, determinants of providing employees H1N1 influenza training, respiratory hygiene education, offering H1N1 vaccine to employees, and higher infection prevention intervention scores were size of the business (with larger businesses implementing more interventions, such as providing education and vaccine, than smaller businesses) and being a health care agency., Conclusion: Businesses should continue to improve business continuity and pandemic plans to prepare for the next biologic event (ie, pandemic, bioterrorism attack, or emerging infectious disease outbreak)., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Only limited data are available on US business continuity activities related to biologic events., Methods: A questionnaire was administered to human resource professionals during May-July 2011 to assess business continuity related to biologic events, incentives businesses are providing to maximize worker surge capacity, and seasonal influenza vaccination policy. Linear regressions were used to describe factors associated with higher business continuity and pandemic preparedness scores. The χ(2) and Fisher exact tests compared health care versus non-health care businesses on preparedness indicators., Results: Possible business continuity and pandemic preparedness scores ranged from 0.5 to 27 and 0 to 15, with average resulting scores among participants at 13.2 and 7.3, respectively. Determinants of business continuity and pandemic preparedness were (1) business size (larger businesses were more prepared), (2) type of business (health care more prepared), (3) having human resource professional as company disaster planning committee member, and (4) risk perception of a pandemic in the next year. Most businesses (63.3%, n = 298) encourage staff influenza vaccination; 2.1% (n = 10) mandate it. Only 10% of businesses (11.0%, n = 52) provide employee incentives, and fewer than half (41.0%, n = 193) stockpile personal protective equipment., Conclusion: Despite the recent H1N1 pandemic, many US businesses lack adequate pandemic plans. It is critical that businesses of all sizes and types become better prepared for a biologic event., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

The 2009 H1N1 pandemic disproportionately affected school-aged children, but only school-based outbreak case studies have been conducted. The purposes of this study were to evaluate US academic institutions' experiences during the 2009 H1N1 pandemic in terms of infection prevention interventions implemented and to examine factors associated with school closure during the pandemic. An online survey was sent to school nurses in May through July 2011. Hierarchical logistic regressions were used to determine predictive models for having a mandatory H1N1 vaccination policy for school nurses and school closure. In all, 1,997 nurses from 26 states participated. Very few nurses (3.3%, n=65) reported having a mandatory H1N1 influenza vaccination policy; nurses were more likely than all other school employees (p<.001) to be mandated to receive vaccine. Determinants of having a mandatory H1N1 vaccination policy were being employed by a hospital or public health agency, and the school being located in a western or northeastern state. Factors related to school closure included being in a western or northeastern state, having higher H1N1-related morbidity/mortality, being a school nurse employed by a public health agency or hospital, and being a private school. The most commonly implemented interventions included encouraging staff and students to exercise hand hygiene and increasing classroom cleaning; least commonly implemented interventions included discouraging face-to-face meetings, training staff on H1N1 influenza and/or respiratory hygiene, and discouraging handshaking. Schools should develop and continue to improve their pandemic plans, including collaborating with community response agencies.

Background: School pandemic preparedness is essential, but has not been evaluated., Methods: An online survey was sent to school nurses (from state school nurse associations and/or state departments of education) between May and July 2011. Overall school pandemic preparedness scores were calculated by assigning 1 point for each item in the school's pandemic plan; the maximum score was 11. Linear regression was used to describe factors associated with higher school pandemic preparedness scores. Nurse influenza vaccine uptake was assessed as well., Results: A total of 1,997 nurses from 26 states completed the survey. Almost three-quarters (73.7%; n = 1,472) reported receiving the seasonal influenza vaccine during the 2010-11 season. Very few (2.2%; n = 43) reported that their school/district had a mandatory influenza vaccination policy. Pandemic preparedness scores ranged from 0 to 10 points, with an average score of 4.3. Determinants of school pandemic preparedness were as follows: planning to be a point of dispensing during a future pandemic (P < .001), having experienced multiple student or employee hospitalizations and/or deaths related to H1N1 during the pandemic (P = .01 or <.05, respectively), having a lead nurse complete the survey (P < .001), and having the school nurse study participant be a member of the school disaster planning committee (P < .001)., Conclusions: US schools must continue to address gaps in pandemic planning., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Primary polydipsia, excessive fluid intake without medical cause, is present in over 20% of seriously and persistently ill psychiatric inpatients. The long-term effects of primary polydipsia on longevity have not previously been examined. Inpatients in a psychiatric hospital were screened for polydipsia in 1985. Those identified to be polydipsic, the majority of whom suffered from schizophrenia, were re-evaluated in 2005 and compared with a control group of non-polydipsic patients. Chart reviews were conducted and follow-up data were obtained. Of 172 patients at the time of screening, 48 suffering from schizophrenia either had or went on to develop polydipsia; 42 non-polydipsic patients with schizophrenia from the original survey were randomly selected as controls. Primary polydipsia had a significant negative effect on longevity. The median age at death (age at which 50% of cases have died) was 59 years for polydipsic patients and 68 for non-polydipsic control patients. Adjusting for duration of schizophrenia, smoking, and diagnosis, a patient with polydipsia had a 74% greater chance of dying before a non-polydipsic patient (a hazard ratio of 2.84 [95% Confidence Interval (CI): 1.22-6.64]). Outcome was worst in patients with severe polydipsia: the median age at death was 57 years and a patient with severe polydipsia had a 75% greater chance of dying before a non-polydipsic patient (hazard ratio of 3.36 [95% CI: 1.31-8.60]). When polydipsia is associated with schizophrenia, mortality is increased in comparison to that in patients with schizophrenia who do not drink water to excess.

To investigate the prevalence of sleep disorders and their symptoms in children with headaches, 64 patients in the outpatient clinics of the University of Chicago Department of Pediatric Neurology were interviewed. Investigated disorders included excessive daytime sleepiness, narcolepsy, insomnia, sleep apnea, restlessness, and parasomnias. Unlike previous studies, subjects were compared with matched control patients by age and sex. Both headache and nonheadache groups completed a 111-item questionnaire detailing sleep symptoms and behaviors. It was found that children with headaches have a significantly higher prevalence of excessive daytime sleepiness, narcolepsy, and insomnia than children without headaches (P < 0.005), which is consistent with prior literature. A similar result was obtained in examining only migraines. However, we did not find a significantly higher prevalence of symptoms of sleep apnea, restlessness, and parasomnias, which contradicts previous literature. Also, the effect of medications taken by headache patients as a confounding factor was insignificant. Overall, pediatricians may find it beneficial to ask about daytime sleepiness, narcolepsy, and insomnia when treating a headache patient.

Over a 3-year period 5457 indigent patients were scored for risk of preterm birth and 4595 women were delivered at greater than or equal to 20 weeks' gestation. Patients at high risk (18.1%) were randomized into control and intervention groups. The latter group received weekly cervical examinations and instruction regarding subtle symptoms and signs of preterm labor. Medical providers received similar instruction. There was no difference in preterm births between control and intervention groups (20.8% vs. 22.1%). Medical providers, convinced of preterm birth prevention during year 1 of the study, defeated the study design by giving preterm birth precautions to all patients. In turn, preterm births decreased from 13.7% (year 1) to 9.3% (year 2, p less than 0.001) and remained stable in year 3 (8.7%). Preterm births during year 1 and the 8 months preceding year 1 were not different. Significant differences in preterm births between private and indigent study patients during these two periods (p less than 0.001) disappeared during years 2 and 3 of the study.