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The National Survey of SSI Children and Families (NSCF) is the first nationally representative survey since 1978 of noninstitutionalized children and young adults who currently receive or formerly received Supplemental Security Income (SSI). Over 8,500 interviews were completed between July 2001 and June 2002. The primary objective of the NSCF is to provide data to support research and policy evaluation on the current cross section of children (ages 0 to 17) and young adults (ages 18 to 23) receiving SSI. Following that objective, the survey was designed to answer questions such as those presented below. What are the general characteristics of children and young adults receiving SSI and their families? What are the patterns of access to and utilization of health care among children and young adults receiving SSI? What services are utilized by children and young adults receiving SSI? What are the unmet health care and service needs of children and young adults receiving SSI? What costs are associated with caring for a disabled child? What is the impact on the family of having a disabled child? What is the status of young adults with disabilities as they make the transition to adulthood? How well are they prepared for that transition? In addition, the NSCF questionnaire and sample were designed to be comprehensive enough and large enough to address numerous additional policy issues as they emerge. The NSCF fills a gap in the data available to policy analysts by addressing a wide range of topics that cannot be addressed with SSI administrative data and by providing a large sample in contrast to major national survey databases that cover this target population fairly sparsely. A companion article to this overview describes general characteristics of SSI beneficiary children and their families (see Rupp and others 2005/2006, pages 21-48 of this issue). Other topics being examined include disability-related expenditures for SSI children and young adults and labor force participation of the parents of SSI children. The NSCF data files are accompanied by a detailed User's Manual, which includes a detailed codebook and information about the NSCF sample design, questionnaire design and content, data collection procedures, variable construction, editing, and variance estimation procedures. In order to facilitate research, the Social Security Administration published the NSCF Public-Use File and survey documentation on its Web site. These products are available at http://www.socialsecurity.gov/disabilityresearch/nscf.htm. The NSCF is an outstanding tool for conducting research and policy analysis regarding children and young adults receiving SSI.

This article provides a nationally representative profile of noninstitutionalized children 0 to 17 years of age who were receiving support from the Supplemental Security Income (SSI) program because of a disability. To assess the role of the SSI program in providing assistance to low-income children with disabilities and their families, it is important to obtain detailed information on demographic characteristics, income and assets, health and disabilities, and health care utilization. Yet administrative records of the Social Security Administration do not contain many of the relevant data items, and the records provide only an incomplete picture of the family relationships affecting the lives of children with disabilities. The National Survey of SSI Children and Families fills this gap. This summary article is based on survey interviews conducted between July 2001 and June 2002 and provides some highlights characterizing children with disabilities who were receiving SSI and their families. Most children receiving SSI (hereafter referred to as "SSI children") lived in a family headed by a single mother, and less than one in three lived with both parents. A very high proportion, about half, were living in a household with at least one other individual reported to have had a disability. About 70 percent of children received some kind of special education. SSI support was the most important source of family income, with earnings a close second. On average, SSI payments accounted for nearly half of the income for the children's families, and earnings accounted for almost 40 percent. When all sources of family income were considered, slightly more than half (54 percent) of SSI children lived in families above the poverty threshold, a notable fact given that the federal SSI program guarantees only a subpoverty level of income. However, beyond these averages there was substantial variation, with some children living in families with income well below the poverty threshold and others having income well over 200 percent of the poverty threshold. About one-third of SSI children lived in families owning a home, two-thirds lived with parents or guardians with at least one car, and about 40 percent lived with parents or guardians with zero liquid assets. Less than 4 percent lived with adults who owned stocks, mutual funds, notes, certificates of deposit, or savings bonds. The Social Security Administration's administrative records contain only a limited amount of information about disability diagnoses. The National Survey of SSI Children and Families supplements those records with data from an array of questions on functional limitations, self-reported health, and the perceived severity of disabilities. The data suggest that a great degree of variation in severity exists within the childhood caseload, as reflected in reports of the presence or absence of six functional limitations, perceived overall health status, and perceived impact of disability on the child's ability to do things. Overall, 36 percent of the children were reported to have had disabilities that affected their abilities to do things "a great deal," and for 21 percent their difficulties had very little or no impact. Physical disabilities were most common among children aged 0 to 5, and mental disabilities dominated the picture for the other two age groups: 6 to 12 and 13 to 17. Virtually all SSI children are covered by some form of health insurance, with Medicaid being by far the most common source of health insurance coverage. Just as in the case of the severity of disabilities, substantial variation was reported in health care utilization among SSI children. Almost 30 percent of children had two or fewer doctor visits during the 12 months preceding the interview, and close to 50 percent had five or more doctor visits. About four-fifths of the children had no reported hospitalizations or surgeries during the previous year. More than 40 percent of the children visited an emergency room during the previous year, most of them more than once. Importantly, no out-of-pocket costs associated with medical care were reported for more than two-thirds of the children, and only about 3 percent had annual expenses exceeding $1,000 for physical and mental health care. This finding suggests that SSI payments are not used to cover medical expenses for the overwhelming majority of children. The use of supportive therapies varied widely among SSI children: more than half reported having used physical, occupational, or speech therapy; only 8 percent used respite care for the parents or other family members. An analysis of the perception of the survey respondents shows that more than one-third of children had unmet needs for mental health counseling services, and about three-quarters of families had unmet needs for respite care. In several service categories, the proportion perceived to have had unmet service needs was around 10 percent or less. In the dominant service category of physical, occupational, and speech therapy, only 11 percent perceived to have had unmet service needs.

Is it more effective to reduce poverty among the elderly by increasing the benefits paid by the Supplemental Security Income (SSI) program or by increasing eligibility for the program? This paper answers that question from a policymaker's perspective. At given program cost levels, we compare the potential reduction in poverty from increasing benefit levels to the potential reduction associated with a variety of policy proposals that would increase eligibility for the program. This paper employs a microsimulation model containing an eligibility and benefits calculator, a participation model, and an optimization algorithm. The data are from the Survey of Income and Program Participation supplemented by the administrative records of the SSI program. The results show that increasing eligibility by relaxing the restrictions of the means tests can be more effective in reducing poverty than raising benefit levels.

Rationale and Objectives: Contrast-carrying liposomes are potentially useful as computed tomography (CT) blood-pool agents. In the present study, preliminary safety, pharmacokinetics, and the CT imaging behavior of continuously extruded iopromide-carrying liposomes were studied., Methods: Iopromide liposomes were prepared by continuous high-pressure extrusion. Cell membrane-damaging characteristics were assessed in vitro in dog erythrocytes. Acute and subchronic toxicity and pharmacokinetics parameters were determined in rats. Computed tomography imaging efficiency was studied in rabbits., Results: The iopromide-carrying liposomes caused only minor morphological changes in dog erythrocytes. The median lethal dose in rats was approximately 4.5 g of total iodine per kilogram of body weight. In a subchronic tolerance study in rats that were administered six doses of 1 g iodine per kilogram twice a week, no adverse effects were observed. The pharmacokinetics in rats was dose dependent, and elimination of iopromide was almost complete within 7 days after intravenous administration. In rabbits, at a dose of 300 mg total iodine per kilogram, the iopromide-carrying liposomes displayed prolonged blood circulation, with mean CT density differences > 60 Hounsfield units (aorta) for up to 10 minutes., Conclusions: The iopromide liposomes were well tolerated, almost completely excreted, and have potential as a CT blood-pool imaging agent.

This article simulates eligibility for Supplemental Security Income (SSI) among the elderly, analyzes factors affecting participation, and looks at the potential effects of various options to modify financial eligibility standards for the federal SSI program. We find that in the estimated noninstitutional elderly population of 30.2 million in the United States in 1991, approximately 2 million individuals aged 65 or older were eligible for SSI (a 6.6 percent rate of eligibility). Our overall estimate of the rate of participation among eligible elderly is approximately 63 percent, suggesting that more than a third of those who are eligible do not participate in the program. The results of our analysis of factors affecting participation among the eligible elderly show that expected SSI benefits and a number of demographic and socioeconomic variables are associated with the probability of participation. We also simulate the effects of various policy options on the poverty rate, poverty gap, annual program cost, the number of participants, and the average estimated benefits among participants. The simulations consider the potential effects of five policy alternatives: Increase the general income exclusion (GIE) from $20 to $80. Increase the earned income exclusion (EIE) from $65 to $260. Increase the federal benefit rate (FBR) by $50 for individuals and $75 for couples and eliminate the GIE. Increase the asset threshold to $3,000 for individuals and $4,500 for couples. Increase the asset threshold to $6,000 for individuals and $9,000 for couples. Using 1991 microdata from the Survey of Income and Program Participation (SIPP) matched to Social Security Administration administrative records and making adjustments reflecting aggregate program statistics, we present the results of our simulations for December 1999. The results show substantial variation in the simulated effects of the five policy alternatives along the various outcome dimensions considered. The simulated effects on the poverty gap of the elderly population range from a 7.9 percent reduction ("Increase the GIE from $20 to $80") to a 0.1 percent reduction ("Increase the EIE from $65 to $260"). All simulated interventions are expected to increase the rate of SSI participation among the elderly from a high of 20.3 percent ("Increase the GIE from $20 to $80") to a low of 0.5 percent ("Increase the EIE from $65 to $260"). We also find that the interventions that have greater estimated effects in terms of increased participation and reduced poverty tend to cost more. At the high end, we estimate that increasing the GIE from $20 to $80 could raise annual federal SSI cash benefit outlays by about 46 percent, compared with only 0.9 percent for increasing the EIE from $65 to $260. Similar to the EIE intervention, raising the resource thresholds by 50 percent would reduce the overall poverty gap of the elderly by only 0.2 percent, would increase SSI participation only modestly (by 1.3 percent), but would entail slightly higher program costs (by 1.4 percent). Increasing the asset threshold by 200 percent would have higher estimated effects on all three outcomes, but it would still be associated with relatively low increases in both costs and benefits. Finally, the simulated effects on the three key outcomes of increasing the FBR by $50 for individuals and $75 for couples, combined with eliminating the GIE, are relatively large but are clearly less substantial than increasing the GIE from $20 to $80. This work relies on data from the SIPP matched to administrative data on federal SSI benefits that provide a more accurate picture of SSI participation than has been feasible for previous studies. We simulate eligibility for federal SSI benefits by applying the program rules to detailed information on the characteristics of individuals and couples based on the rich array of demographic and socioeconomic data in the SIPP, particularly the comprehensive information SIPP provides on assets and monthly income. A probit model is estimated to analyze factors affecting participation among the eligible elderly. Finally, we conduct the policy simulations using altered program rules represented by the policy alternatives and predicted participation probabilities to estimate outcomes under simulated program rules. We compare those simulated outcomes to observed outcomes under current program rules. The results of our simulations are conditional on the characteristics of participants and eligibles in 1991, but they also reflect aggregate adjustments capturing substantial changes in overall participation and program benefit levels between 1991 and 1999.

Medicare buy-in programs are designed to reduce out-of-pocket expenses of beneficiaries with modest income and assets. This article provides estimates of the size of the Medicare beneficiary population eligible for the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the Qualified Individual-1 (QI-1) program. The buy-in programs use the same resource limits (twice those used in the Supplemental Security Income (SSI) program) but different thresholds for determining income eligibility. The QMB program uses 100 percent of the poverty line as the cutoff, QI-1 covers persons above 120 percent but at or below 135 percent of the poverty line, and the SLMB program is in between. Making informed judgments about the rate of participation in the buy-in programs and the need for outreach requires an accurate estimate of the size of the eligible population. If that population is underestimated, policymakers might come to unduly optimistic conclusions about current buy-in participation. In contrast, an overestimate may make current participation seem too low. If policymakers react to an upwardly biased estimate of the eligible population by increasing outreach, they are bound to be disappointed by the results of that effort. Estimates of the eligible population from past studies of the QMB and SLMB programs range from 5.1 million to 9.1 million. In the absence of new information, it is difficult to judge the accuracy of those estimates because the methodologies had substantial shortcomings that might bias the results. The most common shortcomings include the lack of high-quality, monthly income data and the lack of information on assets from the same data file that was used to estimate participation and income eligibility for Medicare. The current study uses the most recently available (as of August 2000) Survey of Income and Program Participation (SIPP) file that is matched to the Social Security Administration's (SSA's) administrative records. The data file covers 1995 information. Estimates were also obtained using 1991 data to assess the sensitivity of eligibility estimates to the year chosen. The SIPP has several major advantages over other data sources because it contains relevant, high-quality information on both income and assets for establishing financial eligibility for the buy-in programs. First, the SIPP collects detailed and conceptually appropriate information on monthly, rather than annual, income and therefore has more complete information about income than do other surveys. As a result, SIPP-based estimates of poverty are substantially lower than estimates based on the Current Population Survey. Second, the SIPP also collects information on assets at the individual level. Thus, the survey provides enough detail to measure the major income and asset exclusions directly. Finally, the SIPP data are matched to SSA administrative records: Medicare eligibility can therefore be accurately measured, and self-reported data on Social Security and SSI benefits can be replaced with more accurate monthly information. Our 1995 simulation estimates that approximately 4.8 million persons in the U.S. noninstitutionalized population were eligible for the QMB program and an additional 1.6 million for the SLMB program. The total--roughly 6.5 million--is within the range of estimates from past studies but is closer to the lower end, suggesting that the eligible population is smaller than was previously believed. When the estimated QI-1 eligible population of 0.9 million is added, the total for the three buy-in programs is 7.4 million. Because the QI-1 program did not exist in 1995, only the estimated 6.5 million QMBs and SLMBs would actually have been eligible to receive benefits. The 7.4 million figure represents the 1995 Medicare beneficiaries who would be eligible for buy-in under program rules for 2000. Adjusting that number to account for increases in the Medicare population between 1995 and 1999 yields an estimated eligible population of 7.8 million in 1999. Compared with other elderly Medicare recipients, eligible elderly QMBs and SLMBs have poorer health, more functional limitations, and higher rates of health care use. Thus, not only are their income resources relatively limited, but their need for potentially expensive medical care is also greater. Similar differences were not found in health, functional limitations, and health care use among disabled participants in the QMB and SLMB programs. Our estimates imply that about 2.5 million noninstitutionalized individuals were eligible for but not enrolled in the QMB and SLMB programs in 1999. That finding suggests that fewer eligibles may be available for targeting by outreach efforts than was previously believed. Outreach may be more difficult than it would be with a larger eligible population. (ABSTRACT TRUNCATED)

During the past several years, the U.S. social safety net has gone through substantial changes involving an emphasis on personal responsibility and incentives, the shift of certain responsibilities to the states, and new limits on entitlements for benefits. Two pieces of recent legislation affected the Social Security Administration's (SSA's) disability programs. Section 105 of Public Law 104-121, enacted on March 29, 1996, mandated the removal of persons from the Supplemental Security Income (SSI) and Social Security Disability Insurance (DI) rolls for whom drug addiction and alcoholism (DA&A) were material to the determination of disability. It eliminated allowances on the basis of DA&A immediately and required the termination of benefits to all persons receiving benefits at the time of enactment. The other major piece of legislation was the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, which was later amended by the Balanced Budget Act (BBA) of 1997. PRWORA converted the Aid to Families with Dependent Children (AFDC) program from an open-ended entitlement program into a block grant, Temporary Assistance for Needy Families (TANF), incorporating time limits on the receipt of benefits as well as strict work requirements. PRWORA also tightened child eligibility for SSI, narrowed eligibility for noncitizens, and reduced funding for food stamps. The BBA restored SSI eligibility for noncitizens receiving SSI prior to August 1996 and for legal noncitizens residing in the United States prior to August 1996 who become disabled in the future. SSA designed three studies to assess the effects of this legislation. Two of the studies focused on direct effects on SSA's disabled beneficiary population, targeting drug addicts and alcoholics and SSI children. The third study focused on the indirect effects of PRWORA, particularly the replacement of AFDC with TANF, on SSA's programs. The three studies were tied together by a concern of the overall effects--direct or indirect--of the legislative changes on SSA's beneficiary populations and a host of interrelated evaluation issues. The key methodological challenge of these evaluations is the nonexperimental nature of the evidence. The legislative pieces mandating the changes designed to affect SSA's target populations were implemented nationally, without prior demonstration projects. Nonexperimental strategies, such as comparison group designs, must therefore be used to measure the effects of interest. Other challenges relate to the time frames. Since implementing the changes requires a certain amount of time, and outcomes are realized over a period of time after that, the information that can be made available to interested policymakers in the short run is inherently limited to descriptive data on the populations affected and to impressionistic evidence from case studies and process study analyses. The timing problem is particularly acute with respect to measuring the indirect effects of replacing AFDC with TANF, because the most important likely effects will occur over a period of several years, and this time frame may substantially vary across states as a result of the decentralized nature of TANF programs. Finally, the analyses that can be conducted are constrained by the lack of relevant data from existing surveys. Administrative record data alleviate the need for survey information for some purposes, but the lack of survey data still seriously constrains the analyses that can be done in the short term. Because of these methodological challenges, SSA designed an evaluation strategy that uses several methods and data sources, including quantitative analyses of data from surveys and administrative records (particularly data from the Survey of Income and Program Participation, or SIPP, matched to data from administrative records) and qualitative analyses through case studies. (ABSTRACT TRUNCATED)

The Social Security Administration (SSA) initiated Project NetWork in 1991 to test case management as a means of promoting employment among persons with disabilities. The demonstration, which targeted Social Security Disability Insurance (DI) beneficiaries and Supplemental Security Income (SSI) applicants and recipients, offered intensive outreach, work-incentive waivers, and case management/referral services. Participation in Project NetWork was voluntary. Volunteers were randomly assigned to the "treatment" group or the "control" group. Those assigned to the treatment group met individually with a case or referral manager who arranged for rehabilitation and employment services, helped clients develop an individual employment plan, and provided direct employment counseling services. Volunteers assigned to the control group could not receive services from Project NetWork but remained eligible for any employment assistance already available in their communities. For both treatment and control groups, the demonstration waived specific DI and SSI program rules considered to be work disincentives. The experimental impact study thus measures the incremental effects of case and referral management services. The eight demonstration sites were successful in implementing the experimental design roughly as planned. Project NetWork staff were able to recruit large numbers of participants and to provide rehabilitation and employment services on a substantial scale. Most of the sites easily reached their enrollment targets and were able to attract volunteers with demographic characteristics similar to those of the entire SSI and DI caseload and a broad range of moderate and severe disabilities. However, by many measures, volunteers were generally more "work-ready" than project eligible in the demonstration areas who did not volunteer to receive NetWork services. Project NetWork case management increased average annual earnings by $220 per year over the first 2 years following random assignment. This statistically significant impact, an approximate 11-percent increase in earnings, is based on administrative data on earnings. For about 70 percent of sample members, a third year of followup data was available. For this limited sample, the estimated effect of Project NetWork on annual earnings declined to roughly zero in the third followup year. The findings suggest that the increase in earnings may have been short-lived and may have disappeared by the time Project NetWork services ended. Project NetWork did not reduce reliance on SSI or DI benefits by statistically significant amounts over the 30-42 month followup period. The services provided by Project NetWork thus did not reduce overall SSI and DI caseloads or benefits by substantial amounts, especially given that only about 5 percent of the eligible caseload volunteered to participate in Project NetWork. Project NetWork produced modest net benefits to persons with disabilities and net costs to taxpayers. Persons with disabilities gained mainly because the increases in their earnings easily outweighed the small (if any) reduction in average SSI and DI benefits. For SSA and the federal government as a whole, the costs of Project NetWork were not sufficiently offset by increases in tax receipts resulting from increased earnings or reductions in average SSI and DI benefits. The modest net benefits of Project NetWork to persons with disabilities are encouraging. How such benefits of an experimental intervention should be weighed against costs of taxpayers depends on value judgments of policymakers. Because different case management projects involve different kinds of services, these results cannot be directly generalized to other case management interventions. They are nevertheless instructive for planning new initiatives. Combining case and referral management services with various other interventions, such as longer term financial support for work or altered provider incentives, could produc

This article describes the development of SSA's administrative records database for the Project NetWork return-to-work experiment targeting persons with disabilities. The article is part of a series of papers on the evaluation of the Project NetWork demonstration. In addition to 8,248 Project NetWork participants randomly assigned to receive case management services and a control group, the simulation identified 138,613 eligible nonparticipants in the demonstration areas. The output data files contain detailed monthly information on Supplemental Security Income (SSI) and Disability Insurance (DI) benefits, annual earnings, and a set of demographic and diagnostic variables. The data allow for the measurement of net outcomes and the analysis of factors affecting participation. The results suggest that it is feasible to simulate complex eligibility rules using administrative records, and create a clean and edited data file for a comprehensive and credible evaluation. The study shows that it is feasible to use administrative records data for selecting control or comparison groups in future demonstration evaluations.

History and Admission Findings: A 75-year-old woman was admitted because of colicky upper abdominal pain. Physical examination was unremarkable., Investigations: Alkaline phosphatase and gamma-glutamyl transpeptidase activities as well erythrocyte sedimentation rate were increased. Sonography revealed mild enlargement of the hepatocholedochal duct to 1.1 cm. Retrograde endoscopy showed a band-like immobile structure in the cystic duct., Treatment and Course: At operation the hepatocholedochal duct was found to contain a greenish mucinous mass: no cause was discovered. Three years later a tumor, 1 x 0.5 cm, was found in the common hepatic duct at sonography, with clinical signs of recurrent chronic cholitis and early liver damage. Because of hepatic dysfunction and hypersplenism no surgical intervention was undertaken. When cholestasis progressed further, a partial full-thickness resection of the hepatic duct with removal of the tumor and the mucinous bile had to be performed two years later. Histological examination revealed a villous adenoma with slight epithelial dysplasia and mucus formation., Conclusions: Villous bile duct adenoma is a very rare cause of cholestasis. Mucous production can lead to mucinous bile, with resulting chronic cholecystitis and secondary biliary cirrhosis. The adenoma should be completely excised because of the danger of malignant transformation and risk of local recurrence.

Two aspartic proteinases, plasmepsins I and II, are present in the digestive vacuole of the human malarial parasite Plasmodium falciparum and are believed to be essential for parasite degradation of haemoglobin. Here we report the expression and kinetic characterisation of functional recombinant plasmepsin I. In order to generate active plasmepsin I from its precursor, an autocatalytic cleavage site was introduced into the propart of the zymogen by mutation of Lys110P to Val (P indicates a propart residue). Appropriate refolding of the mutated zymogen then permitted pH-dependent autocatalytic processing of the zymogen to the active mature proteinase. A purification scheme was devised that removed aggregated and misfolded protein to yield pure, fully processable, proplasmepsin I. Kinetic constants for two synthetic peptide substrates and four inhibitors were determined for both recombinant plasmepsin I and recombinant plasmepsin II. Plasmepsin I had 5-10-fold lower k(cat)/Km values than plasmepsin II for the peptide substrates, while the aspartic proteinase inhibitors, selected for their ability to inhibit P. falciparum growth, were found to have up to 80-fold lower inhibition constants for plasmepsin I compared to plasmepsin II. The most active plasmepsin I inhibitors were antagonistic to the antimalarial action of chloroquine on cultured parasites. Northern blot analysis of RNA, isolated from specific stages of the erythrocytic cycle of P. falciparum, showed that the proplasmepsin I gene is expressed in the ring stages whereas the proplasmepsin II gene is not transcribed until the later trophozoite stage of parasite growth. The differences in kinetic properties and temporal expression of the two plasmepsins suggest they are not functionally redundant but play distinct roles in the parasite.

During the past 25 years since the 'discovery' of the ABR, clinicians world-wide have exploited the clinical utility of this evoked response with many different populations. The 1970s and 1980s saw the development of ABR protocols for increasing the reliability and validity of the response in various clinical situations. Now, in the last decade of the century, advanced technology and the development of increasingly sophisticated software allows more flexibility in these measurements. Thus, ABR testing continues to evolve at a rapid pace. The main focus for ABR in the 1990s has been on developing techniques to improve the quality of the response, decrease the time in which it takes to record the response, and minimize human error through objective response analysis. Some of the major recent developments were reviewed in this chapter. The intent of this review is to provide the researcher and the clinician with an understanding of the underlying principles of the techniques which will be, and are already, available to them on their ABR equipment. Many of these techniques are promising for use with newborns, children, and difficult-to-test populations where time is a limiting factor in the amount of information that can be obtained. We encourage any and all clinicians to experiment with these techniques to determine how each technique might contribute to their particular clinic protocols. As with any new technique, there will be a learning curve associated with understanding the underlying principles, mastering the technical requirements, and realizing the most valuable clinical applications of these methods. Once the procedures become familiar to clinicians and applied in varied clinical settings, it is likely that the neurodiagnostic and audiologic value of ABR will be profoundly enhanced.

We analyze the effects of trends in the age and diagnostic mix of new disability awardee cohorts from 1975 through 1993 on expected duration on the Disability Insurance (DI) and Supplemental Security Income (SSI) rolls. The 1975-93 shift toward younger awardees is estimated to increase duration by 1.4 years for DI and about 5 years for SSI. Much of the increase in SSI duration is attributable to the recent influx of childhood awardees. For working age adults, the DI and SSI trends are comparable. We also estimate that about half of the 1975-93 increase in DI duration is explained by the increase in the proportion of younger DI-insured workers. During the 1993-2006 period, the effect of changes in the age mix of DI-insured workers will be reversed. This will moderate, but not eliminate, likely upward pressures on caseloads arising from the anticipated rise in incidence rates and the future effects of past increases in expected duration.

This article examines factors affecting the growth in the Social Security Administration's disability programs. We synthesize recent empirical evidence on factors affecting trends in applications and awards for Disability Insurance and Supplemental Security Income (SSI) benefits and duration on the rolls. Econometric analyses of pooled time-series, cross-sectional data for States provide strong evidence of business cycle effects on applications and, to a lesser extent, on awards. Substantial effects of cutbacks in State general assistance programs are also found, especially for SSI. Estimated effects of the aging of the baby boomers, growth in the share of women who are disability insured, the AIDS epidemic, and changes in family structure are also presented. Indirect evidence suggests the importance of programmatic factors, especially for awards, and especially in the mental and musculoskeletal impairment categories. The decline in the average age of new awardees has substantially increased duration, particularly for SSI. As a result, caseload growth would be expected to continue even in the absence of future award growth.

The usefulness of a monothermal warm caloric screening test (MWST) for predicting alternate binaural bithermal test abnormalities has been reexamined. Previously, researchers have reported false-negative rates for the MWST ranging from 0% to over 35%. Alternate binaural bithermal test data from 504 consecutive patients were evaluated with MWST failure criteria of 24.5% and 29%, with and without the addition of failure criteria from subtests of the electronystagmography examination. Sensitivity of the MWST alone was high, and improved with additional failure criteria. The specificity levels were correspondingly high. Results support the use of the MWST with adjunctive failure criteria when patients have otherwise normal electronystagmography findings.

Three methods of palliative endoscopic treatment of malignant strictures of the rectum are presented: laser therapy and its combination with the implantation of either plastic prostheses, or self-expanding metal stents. The aim of all procedures is to avoid a colostomy at least in older patients with shorter life expectancy and incurable tumours. The additional application of a stent maintains the luminal patency and prevents the repetition of laser therapy. Since 1988 we have treated 60 patients with these techniques. First, two to six sessions of laser therapy were necessary for recanalization of the stenosis. In the time following this the patients returned two to eight times for regular laser therapy before they died from the carcinoma. In spite of laser therapy one patient developed an obstruction and another suffered from an iatrogenic perforation of the rectal cancer. In both cases a stoma was fashioned. To avoid repetitive laser sessions we successfully inserted a plastic endoprosthesis in seven cases. In another two cases the implantation failed because of perforation and the patients had to undergo surgery. For the next 10 cases we have used flexible self-expanding metal stents. Serious complications or signs of re-obstruction were not observed until the patients' death. The survival time ranged from 2 to 25 months.

Aim of Study: To compare retrospectively the endoscopic treatment of pancreatic pseudocysts by retrograde pancreatic drainage (ERPD), cystogastrostomy (ECG) or cystoduodenostomy (ECD)., Patients and Methods: Between 1987 and 1995 pancreatic pseudocysts were successfully treated endoscopically in 30 patients (13 women, 17 men; mean age 49 [18-89] years): ERPD was accomplished through papillary insertion of 5-7 F prostheses into the cysts or pancreatic duct in 9 patients; ECG achieved drainage of cysts in the body or tail of the pancreas in 15 patients, and ECD for cysts in the head of the pancreas in three. Combined ERPD and ECG was necessary in three patients., Results: Significant pain relief was achieved in all patients, accompanied by increased appetite and weight. Occlusion or dislocation of the prosthesis required renewed endoscopic drainage in three patients. The prostheses were removed, 2-12 months after implantation, when pain relief had occurred and clinical as well as radiological findings had become normal. Recurrence 10-22 months after removal of the drain was observed in four patients, of whom two had a successful second drainage procedure. Surgical intervention became necessary in three patients because of inadequate drainage or (one case) bleeding., Conclusion: These data indicate that endoscopic drainage of pancreatic pseudocysts gives good results with a low complication rate and no deaths. The procedure is thus an alternative to the at present prevailing operative treatment.

History and Clinical Findings: Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation., Investigations: Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding., Treatment and Course: The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding., Conclusion: Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.

We investigated in this study if we would be able to find the correct indication for laparotomy earlier by sonographical examination than by clinical and radiological findings. In 48 of 594 patients with unknown abdominal diseases we found an intestinal obstruction by laparotomy. The indication based on clinical and radiological findings in 37 patients (sensitivity: 77.1%). In comparison the indication for laparotomy was predetermined correctly only after sonographical examination in 45 patients (sensitivity: 89.6%). According to the number of sonographical findings the reliability of the indication for laparotomy increased. The examination by sonography is a valuable tool in the diagnosis of intestinal obstruction.

This article analyzes duration on the Supplemental Security Income (SSI) disability rolls prior to age 65 among children and working-age adults, based on a 10-year followup of 1974-82 cohorts of new awardees by utilizing monthly data from administrative records for 1974-92, and on statistical projections beyond the followup period. Although SSI means testing is responsible for a high proportion of early suspensions, when multiple spells are accounted for, long stays dominate. The estimated mean length of all first SSI spells is 5.5 years. It is 11.3 years for disabled children, 1.3 years for disabled adults eligible for both the Social Security Administration's Disability Insurance (DI) and SSI, and 6.4 years for adults eligible for SSI only. When multiple spells are accounted for, the projected mean total preretirement-age SSI disability stay almost doubles to 10.5 years for all awardees and increases to 26.7 years for children.

Protein disulfide-isomerase (PDI) is the best known representative of a growing family of enzymes with thioredoxin domains. Two such proteins with thioredoxin (Trx) domains, CaBP1 and CaBP2 (ERp72), have previously been isolated from rat liver microsomes. Here we report that they, like PDI are substrates for thioredoxin reductase and will catalyze NADPH-dependent insulin disulfide reduction. The activity of CaBP1 and CaBP2 in this assay was higher than that of PDI but lower than that of E. coli Trx. Furthermore, as isolated the thioredoxin domains of CaBP1 and CaBP2 were in disulfide form as judged by stoichiometric oxidation of 2 and 3 mol of NADPH in CaBP1 and CaBP2, respectively. The redox potential of the active site disulfide/dithiol was estimated from the equilibrium with a mutant E. coli Trx, P34H Trx, with a known redox potential (-235 mV). This showed that CaBP1 and CaBP2, like PDI, have a much higher redox potential than wild type thioredoxin (-270 mV) in agreement with a role in formation of protein disulfide bonds. In conclusion, in vitro CaBP1 and CaBP2 share catalytic properties in thiol disulfide-interchange reactions with PDI. Thus, the well known activity of PDI is not unique in the endoplasmic reticulum and CaBP1 and CaBP2 may be regarded as functional equivalents.

We report on complications of laparoscopic cholecystectomy which needed surgical intervention. These complications occurred in 10 out of 250 patients operated at our hospital and 2 patients admitted with complications. In 3 cases the common bile duct was cut and a hepaticojejunostomy was carried out. 3 patients with an insufficiency of the cystic duct were treated by laparotomy. In 2 cases common bile duct stones had to be endoscopically removed. 1 patient suffered from a pneumothorax due to damage of the diaphragm. The tear was laparoscopically sewn. In one case the abdominal aorta had to be oversewn because of its damage by the needle during creation of the pneumoperitoneum. One patient with adhesions suffered from a perforation of the gut as the trocar was introduced. 2 patients developed an umbilical hernia and underwent surgical herniotomy. In spite of all advantages minimal access surgery of the gallbladder seems to be affected with more serious complications than open approach.

As the Nation's first rigorous large-scale evaluation of vocational rehabilitation (VR) assistance to persons with severe disabilities, the Project NetWork demonstration will provide a wide range of information to policy-makers, researchers, and other interest groups. The evaluation of Project NetWork addresses two key policy questions: Is it feasible to increase participation in VR services among Disability Insurance (DI) beneficiaries and Supplemental Security Income (SSI) applicants/recipients through a combination of intensive outreach, case management, and enhanced work incentives? Do the interventions tested produce net benefits from the perspective of participants, society, the DI Trust Fund, and the Federal Government, as a whole? The study utilizes a randomized field experiment design to evaluate the net impact of the demonstration on participant employment, earnings, receipt of transfer benefits, social and psychological well-being, and other variables of interest to policymakers. A combination of SSA administrative data, information from the demonstration's onsite management information system (MIS), and in-person interviews (containing a rich array of information on disability, health, and attitudes) supports the evaluation. This article summarizes three aspects of the evaluation: Its experimental and sample design; the methods and data to be used to analyze project benefits, costs, and participation; and the challenges faced during demonstration implementation. It also presents preliminary data on the characteristics of Project NetWork participants and eligibles.

We have isolated lambda-phage clones containing the human arylsulfatase B gene region from a genomic lambda 47.1 library. The human arylsulfatase B gene comprises 8 exons interrupted by 7 introns. DNA sequences of all intron-exon boundaries and the 5' flanking region of the gene were determined. All intron-exon splice junctions conformed to the GT/AG consensus sequence. Primer extension analysis revealed multiple start sites 1 to 135 nucleotides 5' of the ATG translational start codon. A 398 bp DNA-fragment of the 5' flanking region exhibits promotor activity when transiently expressed in BHK-21 cells using the bacterial chloramphenicol acetyltransferase gene as a reporter gene. This putative promotor region is located in a CpG island and contains potential Sp1 and AP2 binding sites but lacks typical TATA and CAAT box motifs.

Ca-binding protein 2 (CaBP2) has been described previously as an intracisternal calcium-binding microsomal glycoprotein. We report now the primary sequence of this protein as deduced from the corresponding cDNA. The protein possesses a C-terminal -KEEL retention sequence and three repeats of the thioredoxin-like motive -EFYAPNCGHCK-, and represents the rat homolog of ERp72. In contrast to earlier reports on ERp72, CaBP2 possesses significant proteindisulfide isomerase activity. Furthermore, in contrast to ERp72, CaBP2 is a glycoporotein containing O-linked glycans. The amount of CaBP2 in H-35 Reuber hepatoma cells increases in parallel with that of immunoglobin heavy-chain-binding protein under conditions which lead to impaired glycosylation, while the amount of calreticulin, another KDEL-containing glycoprotein, remains almost unchanged.

Synthetical oestrogens, as well as gestagens may cause metaplastic changes of the endometrial epithelia. While squamous and tubal metaplasia are most often due to oestrogenic stimulation and develop in hyperplastic endometria, mucinous and clear cell metaplasia are stimulated by gestagens and tamoxifen. Tamoxifen seems to act gestagen-like on the endometrium. We present data of 31 patients, who were treated with tamoxifen for breast cancer disease. 3 of these 31 developed endometrial adenocarcinoma.

The use of plasma and factor concentrates for the treatment of coagulation disorders is well established, but many questions remain. The indications for fresh frozen plasma are still not clearly established and excessive use is rampant. The safety of all blood products has not yet been firmly established. Peer review of transfusion practice in a hospital can be achieved by a Hospital Transfusion Committee. The review and analysis of the statistical reports of the transfusion service and strategies for enhancing quality of patient care will be presented.

Heparin exerts its anticoagulant function by accelerating the inhibitory effect of antithrombin III. Low molecular weight heparin (LMWH), which is derived from unfractionated heparin (UFH), exhibits marked anti-Xa activity and minor thrombin inhibition. It has an elevated bioavailability and longer half-life as to the anti-Xa clearance when compared to UFH. Platelet, endothelial and fibrinolytic effects are also involved in antithrombotic action. Clinical trials have shown that LMWH compared to UFH is an equivalent and even advantageous method of antithrombotic prophylaxis in surgical patients and has also a minor risk of bleeding.

In view of the favorable properties of the amniotic membranes as a peritoneal substitute, the following questions were posed: (1) Can the vitality of the amniotic epithelium be preserved by cryoconservation? (2) Which reactive changes occur in an intraabdominal amniotic graft? Animal studies gave the following findings. The vitality of the amniotic cells was not impaired by cryoconservation. A histiocytic demarcation zone developed on the membrane.

This comparative study of long-term results following the substitution of stapes by free cartilage grafts is based on 500 stapedectomies. The patients were operated on by the same surgeon (first author) and followed-up for a period of 5-20 years. Postoperative results, compared with the results of other stapedectomy techniques, demonstrate a statistically significant difference in favour of the cartilage implant technique with respect to the overall functional success rate and the incidence of postoperative complications.