HICNet Medical News Digest Tue, 01 Feb 1994 Volume 07 : Issue 01 Today's Topics: [MMWR 7 Jan 94] Vaccination Coverage of 2 year old Children [MMWR] HIV Prevention Practices of Primary-Care Physicians [MMWR] Occupational Pesticide Poisoning in Apple Orchards Need Clinical Test for Kidney Function +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Compilation Copyright 1994 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. E-Mail Address: Editor: Internet: david@stat.com FidoNet = 1:114/15 Bitnet = ATW1H@ASUACAD LISTSERV = MEDNEWS@ASUACAD.BITNET (or internet: mednews@asuvm.inre.asu.edu) anonymous ftp = vm1.nodak.edu Notification List = hicn-notify-request@stat.com FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Tue, 01 Feb 94 06:52:47 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 7 Jan 94] Vaccination Coverage of 2 year old Children Message-ID: Current Trends Vaccination Coverage of 2-Year-Old Children -- United States, 1991-1992 Protecting children against vaccine-preventable diseases is a national priority in public health. Because approximately 80% of childhood vaccine doses are recommended for administration during the first 2 years of life, vaccination coverage among children must be continuously monitored. National estimates of vaccination coverage were calculated annually from 1959 through 1985 but not for 1986-1990. Beginning in 1991, national estimates of vaccination coverage of preschool children have been available through the National Health Interview Survey (NHIS), a national survey of the civilian noninstitutionalized population conducted by CDC's National Center for Health Statistics (1). This report presents 1992 national estimates of vaccination coverage for 2-year-old children and describes changes from 1991 to 1992. The NHIS collects vaccination information during household interviews. If vaccination records are available, data are abstracted from the record. If such records are not available, information is based on parental recall. For data measurement, 2-year-old children are defined as persons aged 19-35 months. The proportion of children vaccinated were separately analyzed by poverty classification and place of residence. In addition, to assist in targeting vaccination activities based on cultural differences, data were analyzed by race. Limitations in sample size precluded collection of data on ethnicity and analysis of data for races other than black and white. Coverage for measles-containing vaccine was similar in 1991 and 1992 (82.0% and 82.5%, respectively) (Table 1). In contrast, coverage in 1992 was substantially higher than that in 1991 for diphtheria and tetanus toxoids and pertussis vaccine (DTP) and poliovirus vaccine. From 1991 to 1992, coverage for three or more doses of DTP increased from 68.8% to 83.0% and for three or more doses of poliovirus vaccine, from 53.2% to 72.4%. Children living below the poverty level* were less well vaccinated than others. Differences between children living below the poverty level and those living at or above the poverty level ranged from a low of 4.1 percentage points for measles (80.2% vs 84.3%) to a high of 8.1 percentage points for polio (66.6% vs 74.7%). Vaccination levels in urban, suburban, and rural areas were similar in 1992. In general, vaccination levels were lower in black children than in white. In 1992, 71%-72% of children at or above the poverty level were in need of at least one vaccine (Table 2). Among white children, 72%-75% were in need of at least one of the recommended vaccines. Overall, an estimated 1 million 2-year-olds required a single dose of measles-containing vaccine, and 1.6 million 2-year-olds required one or more doses of poliovirus vaccine. Approximately 1 million children had not received at least three doses of DTP vaccine. Reported by: National Immunization Program; Div of Health Interview Statistics, National Center for Health Statistics, CDC. Editorial Note: The findings in this report summarizing NHIS data document the overall continuing problem of undervaccination of children in the United States. However, vaccination coverage for some antigens has improved in some age groups--particularly for vaccination against measles in the preschool population. Estimated measles vaccine coverage for 2-year-olds in 1985 was 61%, compared with 82% in 1991 and 1992; before 1991, the highest previously documented level was 67% in 1982 (CDC, unpublished data, 1993). The recent increase in coverage reflects the national response to increased vaccination levels following the measles resurgence during 1988-1991; as a result of these efforts, the incidence of measles decreased to a historic low in 1993 (2). This report also documents a substantial increase in poliovirus and DTP vaccination levels from 1991 to 1992. At least two factors may account for these increases. First, many state and local public health agencies, in collaboration with national and local private voluntary organizations, have intensified their efforts to vaccinate preschool children, especially since the 1989-1991 measles resurgence. Second, changes in survey methodology between 1991 and 1992 have simplified data collection from parental recall. In 1991, respondents were required to specify the exact ages at which vaccinations were administered for the full number of doses to be credited; however, some parents had difficulty recalling the exact ages at which their child received vaccinations. As a consequence, in 1992, a parental response that the child had received all doses of a particular antigen was accepted; retrospective studies have shown this methodology has enhanced the accuracy of data (CDC, unpublished data, 1993). Because of difficulties in determining vaccination status from parental recall (3), in 1994, the NHIS will include a check of provider records for all children aged 19-35 months, thus allowing for adjustment of overall survey results. In addition, health-care providers will encourage parents to maintain home vaccination records (4). Despite ongoing and substantial efforts to improve the vaccine delivery system in the United States, vaccination levels for 2-year-olds remain below 90%. In addition, coverage varies by and are substantially lower in some population groups, especially those underserved by the health-care system. Differences in vaccination levels among racial/ethnic groups may be influenced by social and cultural phenomena and require special interventions. For example, during 1992 in Los Angeles, 42% of Hispanic preschool children were fully vaccinated by age 24 months, compared with 25% of black children, even though Hispanic parents reported lower mean annual family incomes ($3218 vs. $4596) and lower mean years of education (8.6 years vs. 12.5 years) (CDC, unpublished data, 1993). Limitations in the sample size of the 1992 NHIS preclude estimation of vaccination coverage of Hispanic populations; however, the increased incidence of measles among Hispanics before and during the measles resurgence suggests that overall vaccination coverage is also substantially lower in Hispanics than in white non-Hispanics (5-7). The prevention of vaccine-preventable diseases in the United States will require that uniformly high vaccination levels for preschool children be achieved and sustained in all communities. References 1. Massey JT, Moore TF, Parsons VL, et al. Design and estimation for the National Health Interview Survey, 1985-94. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989. (Vital and health statistics; series 2, no. 110). 2. CDC. Measles--United States, first 26 weeks, 1993. MMWR 1993;42:813-6. 3. Goldstein KP, Kviz FJ, Daum RS. Accuracy of immunization histories provided by adults accompanying preschool children to a pediatric emergency department. JAMA 1993;270:2190-4. 4. CDC. Standards for Pediatric Immunization Practices [Standard 9], 1993:15. 5. Orenstein WA, Atkinson W, Mason D, Bernier RH. Barriers to vaccinating preschool children. J Health Care Poor Underserved 1990;1:315-30. 6. CDC. Measles vaccination levels among selected groups of preschool-aged children--United States. MMWR 1991;40:36-9. 7. Gindler JS, Atkinson WL, Markowitz LE, Hutchins SS. Epidemiology of measles in the United States in 1989 and 1990. Pediatr Infect Dis J 1992;11:841-6. *Poverty statistics are based on definitions developed by the Social Security Administration that include a set of income thresholds that vary by family size and composition. ------------------------------ Date: Tue, 01 Feb 94 06:53:33 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] HIV Prevention Practices of Primary-Care Physicians Message-ID: Effectiveness in Disease and Injury Prevention HIV Prevention Practices of Primary-Care Physicians -- United States, 1992 Primary-care physicians can be important providers human immunodeficiency virus (HIV)-prevention services to their patients. In 1991, 15% of U.S. adults reported having been tested for HIV antibody; of these, 55% reported their most recent HIV test had been in a physician's office or a hospital (1). During 1992, CDC and the Health Resources and Services Administration (HRSA) commissioned a national survey to characterize the types of HIV prevention services provided by primary-care physicians and barriers to the provision of these services. This report summarizes the results of the survey. In October 1992, a questionnaire was mailed to 4011* primary-care physicians who were randomly selected from the American Medical Association (AMA) Physician Masterfile, which comprises all physicians in the United States. The sample was stratified by location, race/ethnicity, and specialty. Two categories of location were defined on the basis of the prevalence of acquired immunodeficiency syndrome (AIDS) in metropolitan statistical areas (MSAs): 1) physicians practicing in the 20 MSAs with the highest prevalence and 2) those practicing in the remaining MSAs. Physicians were asked about their risk assessment of new patients; HIV counseling, testing, and treatment practices; and basic understanding of and attitudes about HIV infection and persons with HIV disease. The data were weighted to adjust for unequal probabilities of selection and for the variability of response rates among the strata. Of the 3735 eligible** physicians, 2545 (68%) responded; of these, 802 were general/family practitioners; 360, pediatrician/adolescent medicine physicians; 683, obstetrician/gynecologists (OB/GYNs); and 700, general internal medicine physicians. Of the 2545 respondents, 1931 (76%) were men. Three hundred eighty (15%) were aged less than 35 years; 1042 (41%), 35-44 years; and 1123 (44%), greater than 44 years. Of 2496 respondents for whom primary practice was known, 1487 (60%) were based in private, single-specialty practices; 442 (18%), in private, multispecialty practices; 299 (12%), in hospitals, public clinics, and community health centers; and 267 (11%), from academia and other institutions. Six hundred two (24%) of the physicians were located in areas with high prevalences of AIDS. Almost all (94%) respondents indicated they "usually" or "always" asked new adult (aged greater than or equal to 19 years) patients about cigarette smoking; however, sexual history-taking was less frequently reported (Table 1): 49% asked about sexually transmitted diseases (STDs), 31% about condom use, 27% about sexual orientation, and 22% about number of sex partners. In comparison, 84% of all physicians asked new adolescent (aged 13-18 years) patients about cigarette smoking, 56% about STDs, 52% about condom use, 34% about number of sex partners, and 27% about sexual orientation. One fourth (25%) of all physicians believed their patients would be offended by questions about their sexual behaviors. The percentage of physicians who indicated they would "likely" or "very likely" encourage HIV testing varied by patient risk category (Table 2) and ranged from 95% (homosexual men with multiple partners and injecting-drug users) to 40% (sexually active adolescent patients). Most physicians (66%) indicated that if HIV testing were indicated for a patient, they would probably provide the test counseling themselves. Factors that either "moderately" or "strongly" influenced physicians to refer for counseling and testing rather than provide it themselves were that counseling was too time consuming (55%), information was insufficient to enable counseling (45%), and they preferred anonymous testing for their patients (42%). Most respondents indicated that their decision to refer was not influenced by inadequate reimbursement (86%) or discomfort with counseling (85%). Ninety-two percent of physicians indicated that they would counsel an HIV-positive patient to reduce the risk for transmitting HIV. In addition, 76%-81% indicated they would counsel the patient to notify sex partners, refer the patient to the local health department for assistance with the notification, or both. Of physicians in OB/GYN practices, 85% indicated they would provide contraceptive services and 47% would provide prenatal care to all women, regardless of their HIV status (Table 3). In comparison, 73% would provide contraceptive services and 29% would provide prenatal care to women with HIV. Physicians who reported they would refer patients with HIV for medical services indicated the primary reasons for referring were their lack of experience with HIV (83%) and the availability of other providers with more expertise in treating HIV infection (94%). Overall, 68% of physicians indicated they believed they had an obligation to take care of someone infected with HIV, and 87% indicated that professional training could help "increase their comfort in caring for AIDS patients." Reported by: J Loft, PhD, W Marder, PhD, Abt Associates, Inc., Chicago. L Bresolin, PhD, R Rinaldi, PhD, American Medical Association. Div of Medicine, Bureau of Health Professions, Health Resources and Svcs Administration. National AIDS Information and Education Program, Office of HIV/AIDS; Women's Health and Fertility Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Sexually Transmitted Diseases and Human Immunodeficiency Virus Prevention, and Behavioral Studies Section, Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC. Editorial Note: Although primary-care physicians may contribute to the prevention of HIV transmission by counseling patients who are at risk, the findings in this report underscore the substantial number of physicians who are missing opportunities to counsel during encounters with patients. To more effectively use these encounters as a means of prevention, physicians first must be knowledgeable about HIV infection and its transmission (2). In addition, they should be made aware of the importance of assessing patients' risk for HIV infection and prepared to counsel patients, based on their risk (3). Therefore, medical schools and professional organizations should continue to emphasize HIV/AIDS prevention and treatment as priorities in training new and practicing physicians. The findings in this report can assist in the development of HIV prevention policies and programs. For example, the reluctance of some physicians to assess the risky sex practices of patients underscores the importance for public health agencies to assist physicians in improving risk assessment and risk-reduction counseling efforts for their patients and patients' partners. These findings may be used by HRSA to improve training strategies and programs for health-care professionals and AMA and other professional organizations to develop training objectives for primary-care physicians. Finally, these findings can assist in efforts to achieve the national health objectives for the year 2000 regarding HIV prevention (4). These objectives include increasing to at least 80% the proportion of persons with HIV infection who have been tested (objective 18.8); increasing to at least 75% the proportion of primary-care and mental health-care providers who provide age-appropriate counseling on the prevention of HIV and other STDs (objective 18.9); and increasing to at least 50% the proportion of primary- care clinics who screen, diagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial STDs (objective 18.13). References 1. Hardy AM. Advance data--AIDS knowledge and attitudes for 1991: data from the National Health Interview Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993. (Advance data no. 225). 2. Gerber AR, Valdiserri RO, Holtgrave DR, et al. Preventive services guidelines for primary care clinicians caring for adults and adolescents infected with the human immunodeficiency virus. Archives of Family Medicine 1993;2:969-79. 3. Valdiserri RO, Holtgrave DR, Brackbill RM. American adults' knowledge of HIV testing availability. Am J Public Health 1993;83:525-8. 4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. *Represents 3% of the total primary-care physician population. **Physicians who were not practicing in one of the primary-care specialties, were practicing out of the country, retired, or deceased were deemed ineligible. ------------------------------ Date: Tue, 01 Feb 94 06:54:13 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Occupational Pesticide Poisoning in Apple Orchards Message-ID: <35m3gc3w165w@stat.com> Epidemiologic Notes and Reports Occupational Pesticide Poisoning in Apple Orchards -- Washington, 1993 During July-December 1993, the Washington Department of Health (WDOH) received and conducted follow-up investigations of 26 reports of occupational illness related to exposure to mevinphos (Phosdrin [Registered]*), an organophosphate (OP) insecticide. The reports involved illnesses during June 13-August 18, 1993, in persons working in 19 different apple orchards; all involved use of mevinphos to control apple aphids. This report summarizes the results of these investigations by WDOH. All the affected workers were men ranging in age from 19 to 72 years (median: 35 years). Eighteen (69%) were Hispanic; eight (31%) were non- Hispanic whites. Twenty-three (88%) of the workers were exposed during mixing/loading or application of mevinphos. The other three (12%) were exposed to mevinphos residues (two while working in close proximity to a recently treated orchard and one after reentering an orchard within 24 hours after it was sprayed). Of the 23 workers exposed during mevinphos mixing/loading or application, 22 had worked on ground applications and used an airblast** system; one worked on an aerial application. All 23 sought medical attention in emergency departments. Twenty-one workers had systemic manifestations characteristic of OP poisoning, including nausea (81%), vomiting (62%), dizziness (43%), visual disturbances (43%), muscle weakness (38%), abdominal pain (29%), headache (24%), sweating (24%), and excessive salivation (5%). Two persons had conjunctivitis only, which was attributed to direct ocular exposure to mevinphos. Of the seven workers who were hospitalized, four required intensive care. Plasma and/or red blood cell cholinesterase activity was depressed to at least 25% below the lower limit of normal in 14 (88%) of the 16 workers tested; for one worker, the level of activity was depressed 97%, and for three, 75%-90%. Atropine was administered to all seven hospitalized workers and to four of the 14 workers with systemic illness who were treated in the emergency department and released. Eighteen (86%) of the 21 workers with systemic effects were exposed to mixtures of mevinphos and less toxic OP pesticides. WDOH investigation of all the poisoning incidents determined that personal protective equipment had been available to all mixers/loaders and applicators, but that in 78% of the incidents, U.S. Environmental Protection Agency (EPA) requirements regarding use of protective equipment*** had not been followed (e.g., respirators, gloves, or goggles had been removed during pesticide handling or leather [instead of rubber] footwear had been used). On August 19, 1993, in response to these reports, the Washington State Department of Agriculture (WSDA) prohibited mixing/loading or application of mevinphos by unlicensed applicators. On August 30, use of mevinphos on apples and pears was temporarily suspended. WSDA will determine before the 1994 pesticide application season (i.e., late spring through late summer) whether this suspension will be permanent. Reported by: C Sagerser, V Skeers, MN, L Baum, MS, M Magana, MD, B Morrissey, MS, B Mason, Pesticide Section; JM Kobayashi, MD, State Epidemiologist, Washington Dept of Health. Surveillance Br, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. Editorial Note: Mevinphos is an acutely toxic (oral LD[subscript]50 3.7-6.1 mg/kg, dermal LD[subscript]50 4.2-4.7 mg/kg [rats]) broad-spectrum OP insecticide (1). EPA classifies mevinphos in its highest toxicity category (Class I), restricts its use to certified applicators or to persons directly supervised by certified applicators, and requires use of protective equipment and mandatory reentry intervals (i.e., time between mevinphos application and safe reentry onto treated fields without use of personal protective equipment). Toxicity of mevinphos is similar to that of ethyl parathion, an OP insecticide that in 1991 was removed from the market for most uses because of its high hazard potential. Like other OPs, mevinphos is readily absorbed through the lungs, gastrointestinal tract, and skin. Typical manifestations of poisoning include nausea, vomiting, miosis, dizziness, headache, muscle weakness and twitching, bradycardia, and generalized hypersecretion. Use of mevinphos is particularly hazardous for apple orchard workers because apples generally require ground (rather than aerial) application of pesticide, hand cultivation, and hand harvesting. In May 1992, sale of phosphamidon, a less toxic OP insecticide used to control apple aphids, was discontinued by the manufacturer. When growers in Washington subsequently began to consider use of mevinphos for aphid control, the manufacturer of mevinphos recommended in early 1993 that WSDA institute additional restrictions on its use. WSDA issued emergency rules for the use of mevinphos on June 14, 1993, which included the requirements that an observer be present during all mixing/loading activities, the EPA-mandated reentry interval be extended from 48 to 96 hours, and warning signs be posted at all treated orchards. Despite these requirements, all but one of the poisonings described in this report occurred after these emergency rules were issued; 22% of the incidents apparently occurred despite reported adherence to all application requirements. The detection of this outbreak and the resulting public health actions by WDOH and WSDA highlight the role of state-based surveillance systems in the recognition and prevention of occupational pesticide-related illness. The cases described in this report represent the first reported hospitalizations of workers in Washington associated with agricultural use of any OP insecticide since implementation of the WDOH pesticide surveillance system in 1990. Although mevinphos was mixed with other OP insecticides in most of the reported incidents, there were no reports to WDOH of severe occupational illness associated with individual use of other compounds. The magnitude of the risk for mevinphos poisoning among Washington agricultural workers cannot be estimated because the total number of workers who may be at risk for exposure to this pesticide is unknown. Occupational poisonings with mevinphos (including fatalities) have been reported in California (2,3) and Florida (4). During 1982-1990, agricultural use of mevinphos in California was associated with 495 (43%) of 1154 reported cases of OP poisoning--more than for any other OP pesticide (5)--and during 1974-1982, mevinphos was among the six leading causes of hospitalization resulting from occupational pesticide poisoning nationally (6,7). As demonstrated by the Washington cases, even when use of mevinphos is strictly regulated and mandated precautions apparently are followed, poisonings occur. Surveillance data have identified a high proportion of Hispanics among cases of agriculturally related pesticide poisoning. This most likely reflects Hispanic prevalence in the U.S. farmworker population (70% of U.S. farmworkers [8]), as well as previously documented risk factors for occupational disease and injury among migrant farmworkers (9), who are predominantly Hispanic (8). In April 1993, EPA identified mevinphos as a pesticide warranting "immediate attention and the implementation of risk-reduction measures" and requested that manufacturers provide information to assist in characterizing the risks for U.S. agricultural workers (10). EPA will continue to assess the risks associated with exposure to mevinphos and the need for additional regulatory measures. References 1. Hayes WJ Jr, Laws ER Jr. Handbook of pesticide toxicity. Volume 2. San Diego: Academic Press, Inc, 1991:1007. 2. Coye MJ, Barnett PG, Midtling JE, et al. Clinical confirmation of organophosphate poisoning of agricultural workers. Am J Ind Med 1986;10:399- 409. 3. Peoples SA, Maddy KT, Edmiston S. Human health problems associated with mevinphos (Phosdrin) in California for the years 1975-1977. Sacramento, California: California Department of Pesticide Regulation, Worker Health and Safety Branch, 1978; publication no. HS-373. 4. Penzell D. Testimony: hearing before the Select Committee on Aging, House of Representatives. Washington, DC: US Congress, House of Representatives, April 24, 1990; committee publication no. 101-770. 5. O'Malley M. Addendum report: mevinphos illness cases 1982-1990 compared to other organophosphate insecticides. Sacramento, California: California Department of Pesticide Regulation, Worker Health and Safety Branch, 1993; publication no. HS-1626A. 6. Savage EP, Keefe TJ, Wheeler HW, Helwic LJ. National Study of Hospitalized Pesticide Poisonings, 1974-1976. Washington, DC: US Environmental Protection Agency, July 1980; report no. EPA-540/9-80/001. 7. Keefe TJ, Savage EP, Wheeler HW. Third National Study of Hospitalized Pesticide Poisonings in the United States, 1977-1982. Fort Collins, Colorado: Colorado State University, Epidemiologic Studies Center, 1990. 8. Mines R, Gabbard S, Samardick R. US farmworkers in the post-IRCA period. Washington, DC: US Department of Labor, Office of the Assistant Secretary for Policy, Office of Program Economics, March 1993; research report no. 4. 9. US General Accounting Office. Hired farmworkers: health and well-being at risk. Washington, DC: US General Accounting Office, February 1992; report no. GAO/HRD-92-46. 10. US Environmental Protection Agency. Notification to pesticide manufacturers of data call-in for immediate action on five pesticides. Washington, DC: US Environmental Protection Agency, Special Review and Re- registration Division, April 6, 1993. *Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. **This application technique involves the use of a tractor-drawn sprayer with oscillating nozzles that are oriented in a flat plane and direct the spray mixture into the canopy of the trees for complete coverage. ***Protective suits, chemical-resistant gloves and shoes, goggles or face shields, and an approved respirator are required for ground application. ------------------------------ Date: Tue, 01 Feb 94 06:54:43 MST From: mednews (HICNet Medical News) To: hicnews Subject: Need Clinical Test for Kidney Function Message-ID: Please respond directly to: C_Reyes@rumac.upr.clu.edu My 13 years old son, after a slight throat infection spent more than necessary time in a pool and the bacterial infection went to his kidney. That was 4 months ago. He feels fine but his kidney function is still around 40-50%. The kidney function is measured using the creatinine levels in serum and urine. The creatinine levels are measured using a colorimetric reaction (Jaffe's method) that is not very reliable, according to the book of Clinical Chemistry i have (Tietz). My question is this: Does anybody know of any place were a more reliable method is used than Jaffe's? Is there such a method? Would not it be proper for medical labs to run a control at the same time with the sample to make sure everything is in order(including buffers,etc.), since the diagnosis will be based in results that might differ by 0.1 or 0.2 units? The doctor has prescribed a biopsy in two weeks, followed by corticosteroids or some other immnuno depresant drugs. Any other suggestion is also welcomed. Thanks to all. Cesar Reyes Chemistry Dept Univ. of Puerto Rico Mayaguez, Puerto Rico 00680 (809)-851-0678 Internet: C_Reyes@rumac.upr.clu.edu ------------------------------ End of HICNet Medical News Digest V07 Issue #01 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD -------------------------------------------------------------------------------