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Despite a massive expansion of Medicaid and an upswing in the economy, the total number of Americans uninsured in 1993 was 39.7 million, more than at any time since the passage of Medicaid and Medicare in the 1960s. Since 1989, the ranks of the uninsured have swelled by 6.3 million. Millions more would be uninsured if Medicaid enrollment had not risen dramatically, by 10.5 million people since 1989. Loss of health coverage is a growing problem for middle-income families, women, and children, as it has long been for low-income families. Even in Hawaii, whose employer mandate program is often cited as a model of universal coverage, there was a large increase in uninsurance. Nationwide, the sharp upswing in the number of Americans who are uninsured has coincided with government and corporate policies to encourage medical competition and push people into managed care plans. Republican proposals to limit AFDC benefits threaten to further increase uninsurance, particularly among women and children. Only a Canadian-style single-payer reform can assure universal coverage and simultaneously contain costs.

Objective: To evaluate the influence of tobacco industry campaign donations, district location, and political party affiliation on tobacco control legislation among members of the US Congress., Design: Data were obtained from the Federal Election Commission on money contributed by the 10 leading tobacco political action committees and by tobacco industry-aligned individuals to members of the US House of Representatives (1991-1992) and Senate (1987-1992). Logistic regression analyses were performed using recorded votes and cosponsorship activities concerning tobacco control legislation during the 102nd and 103rd Congresses and membership on the House Congressional Task Force on Tobacco and Health as the dependent variables and tobacco money received, party, district location, and caucus or committee membership as the independent variables., Setting: United States Congress in 1991 and 1992., Interventions: None., Main Outcome Measure: Support for federal tobacco control legislation., Results: The tobacco industry donated approximately $2.4 million to members of Congress from January 1991 through December 1992. House members received an average of $2943 (1991-1992) and senators received an average of $11,593 (1987-1992). The more tobacco money a member received, the less likely the member was to support tobacco control legislation. In the Senate, on a vote to end the taxpayer subsidy of tobacco products in military stores, the odds ratio that senators in the top quartile of tobacco money recipients did not support the measure vs senators in the lowest quartile of tobacco money recipients was 42.2 (95% confidence interval, 4.1 to 430.0; P < .001). In the House, on a vote to end a $3.5 million subsidy to promote American tobacco abroad, the odds that House members in the top third of tobacco money recipients would oppose the legislation were 14.4 times greater (95% confidence interval, 5.5 to 39.0; P < .001) than for House members in the lowest third of tobacco money recipients. Receiving more tobacco money, being a member of the Republican party, and representing a tobacco-producing state were all associated with decreased support for tobacco control issues. The amount of tobacco money received was the variable most strongly and consistently associated with a lack of support for tobacco control legislation, even when we controlled for additional factors such as district location and party., Conclusion: Tobacco industry contributions to members of the US Congress strongly influence the federal tobacco policy process. Unless this influence is diminished through a combination of members refusing tobacco money and campaign finance reform, this process of contributing to death by thwarting tobacco control will continue to claim hundreds of thousands of lives a year.

New data obtained from the Census Bureau shows that the number of Americans without any health insurance increased by 1.3 million between 1989 and 1990, bringing the total number of uninsured to 34.7 million, more than at any time since the passage of Medicare and Medicaid 25 years ago. This increase coincided with a 10.5 percent increase in health spending, the second largest in the past three decades. The number of people covered by Medicaid grew by 3.1 million, due to a one-time expansion of eligibility mandated by Congress, but this was more than counter-balanced by a population growth of 3 million and a decrease of 1.3 million in people covered by private insurance. Had Medicaid not been expanded, the number of uninsured would have increased by 4.4 million. The increase in the uninsured affected virtually all parts of the nation. Seven states had increases of more than 100,000 persons each. Only Texas experienced a decrease of that magnitude, but still had the second highest rate of uninsurance of any state. Of the 1.3 million additional uninsured in 1990, 77 percent were male, 32 percent had family incomes in excess of $50,000 per year, and 74 percent had annual family incomes above $25,000. Fewer than 9 percent had incomes below the poverty line. The numbers of uninsured children and senior citizens fell slightly (but not significantly), while the number of uninsured working-age adults rose by 1.4 million. The number of uninsured workers in each of four of 20 major industry groups increased by more than 100,000 in 1990. None of the industry groups showed a significant decline in the number of uninsured. Among professionals, there were substantial numbers of uninsured doctors, engineers, teachers, college professors, clergy, and others, but all legislators and judges were insured. The data presented here largely predate the recession and understate current problems. In 1991 the number of uninsured will likely reach nearly 40 million. Also, these estimates are based on the number of people uninsured at a single time during 1990; a far higher number were temporarily uninsured at some point during the year. Moreover the Census Bureau survey ignores the problem of the underinsurance of at least 50 million insured Americans. Patchwork public programs are grossly inadequate to plug the holes. A national health program covering all Americans could assure access to care and contain costs.

The effect of selected inhibitors on the thrombin-stimulated burst and the basal oxygen consumption of washed human platelets were investigated and compared with inhibition of the release reaction. Cyanide (0.2 mM) caused complete inhibition of the basal respiration, but only 15% inhibition of the thrombin-stimulated burst of oxygen consumption. Similar differential inhibitory effects were observed with oligomycin, antimycin, rotenone and N-ethylmaleimide. Prostaglandin E1 (0.03 mM) and acetylsalicylic acid (0.8 mM) had little effect on basal respiration, but inhibited the thrombin-stimulated burst of oxygen consumption. N-Ethylmaleimide (0.4 mM) inhibited the release of calcium from platelets by 90%, while prostaglandin E1, acetylsalicylic acid and the above mitochondrial inhibitors caused no more than 30% inhibition of the release reaction. Our results provide evidence that basal respiration and a portion of the thrombin-stimulated burst of oxygen consumption are involved in respiratory chain phosphorylation, and that this component of the thrombin-stimulated burst may be coupled to the maintenance of the release reaction.

A high resolution submillimeter interferometer system for measurement of electron densities in the 10(14)-cm(-3)

Recertification, like taxes, will never draw many supporters from the targeted group. Why should physicians who have had to survive the stiffest of scholastic labors in order to obtain the privilege of a medical education again be asked to prove their continuing worth long after graduation? Apparently because health consumers feel that physicians occupy a critical role and want more tangible evidence that they are keeping up with the explosion of medical knowledge. Dr. Trobe has sought the opinion of Dr. Melvin Rubin, who challenges the assumption that a recertification test will offer a sufficient guarantee of clinical excellence to warrant the expense to the public and the "mental anguish" to physicians, and the opinion of Dr. Sidney Wolfe, who argues that examination is a necessary (though perhaps not sufficient) protection against flagging knowledge and skill.

The effect of thrombin on the oxygen consumption of washed human platelets was measured polarographically with the Clark oxygen electrode. The average basal respiratory rate was 18 plus or minus 1.6 (mean plus or minus S.E.) natoms oxygen per min per 10-9 platelets. Thrombin (1.9 units/ml) caused a 4-13-fold increase in the rate of oxygen consumption (138 plus or minus 14 (mean plus or minus S.E.) natoms oxygen per min per 10-9 platelets). The thrombin-stimulated increase of oxygen consumption was transient, lasting from 1 to 1.5 min before returning to the respiratory rate observed before the thrombin addition. Release of platelet constituents appeared to precede the stimulation of oxygen consumption. These results may provide a basis for explaining the discrepancy in the literature concerning the effects of thrombin on platelet respiration.

Takayasu's arteritis, an inflammatory and obliterative disease of medium and large arteries, is classified as a giant cell arteritis. It has a predilection for the aortic arch and its branches and the pulmonary arteries. Unlike atherosclerotic vascular diseases, Takayasu's arteritis affects young women primarily. Early symptoms may be mainly systemic and may resemble polymyalgia rheumatica. The etiology is unknown, but infectious agents and autoimmunity have been suggested to play a role. Diagnosis is based on symptoms, physical findings, and angiographic findings, because tissue diagnosis rarely is feasible. The two cases reported here represent contrasting phases of Takayasu's arteritis.

A patient with severe hepatic transplant rejection presented with evidence of hypertrophic osteoarthropathy. The classic triad of clubbing, periostitis, and arthritis was present along with typical radiographic and bone scan findings. A second liver transplant was not successful and the patient died secondary to massive bleeding. Although hypertrophic osteoarthropathy is known to occur rarely in association with chronic liver disease, it has not been reported accompanying liver transplant rejection. This syndrome is to be differentiated from other causes of arthritis and musculoskeletal pain in liver transplant patients and may contribute towards additional morbidity in these patients.

The clinical course and muscle biopsy findings of four adults with sarcoidosis who developed a myopathy are described. Three patients had evidence of an inflammatory myopathy and elevated CPK. Two patients had no detectable granulomas at muscle biopsy and may represent a separate autoimmune disorder (polymyositis) concurrent with sarcoidosis. Asymptomatic muscle disease in sarcoidosis probably occurs with a much greater frequency than symptomatic disease. Isolated sarcoid myopathy without prior or concurrent organ involvement has been described, but comprehensive autopsy studies to confirm this are lacking. The origin of symptoms associated with granulomas is obscure and may be mediated through the effects of lymphokines and monokines. Corticosteroids seem to play a useful role in therapy, but treatment over a prolonged period may be necessary. The use of cytotoxic agents is largely untested.