pnas International Journal of Health Geographics Proc Natl Acad Sci USA PNA 0959-8138 British Medical Journal Fake Location 10092260 Papers 271 Papers 218 Papers 209 Fake title of an article series Fake description of an article series Systematic review of day hospital care for elderly people

The Final Recount

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Anne Forster is the current editor of the OASIS Microwave Journal, responsible for Technical Committee and Developments. She received her BE and PhD in electrical engineering from the University of Queensland, Brisbane, Australia. Currently, she is professor in the School of Electronic Engineering at the University of Finlandia, where she holds the chair in Microwave Electronics

Pollard Thomas D. III

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This essay constitutes the second article in the “Genome Annotation Series” initiated by Thomas D. Pollard, Essay Editor. The first essay, by J.S. Berg, B.C. Powell, and R.E. Cheney, appeared in the April 2001 issue of Molecular Biology of the Cell (Vol. 12, Issue 4, pp 780–794).

Taylor James C. Ph D Dorelco Corporation Ltd. Institute of Infectious Disease Research Oberlin, Washington 96204; United States

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Young John The Honorable consultant physiciana Langhorne Peter senior lecturerb on behalf of the Day Hospital GroupaDepartment of Health Care for the Elderly, St Luke’s Hospital, Bradford BD5 0NA, bAcademic Section of Geriatric Medicine, Royal Infirmary, Glasgow G4 0SF

Fake Notes Title

Contributors: AF planned and initiated the review, conducted literature searches, assessed the trials, drafted and redrafted the final report. JY planned and initiated the review, assessed trials, and redrafted the final report. PL planned the review, assessed trials, provided methodological support, and redrafted the final report. The day hospital group is formed from the authors of this systematic review and the authors of the original trials who provided additional information about trial procedures and data: S Burch, J Longbottom, M Mckay, C Borland, T Prevost (Huntingdon); Kaisu Pitkala (Helsinki); John Gladman (Nottingham); Susan Hedrick, M L Rothman, M K Chapko, J L Ehreth, P Diehr, T S Inui, R T Connis, P L Grover, J R Kelly (United States); E Hui, C Lum, R L C Kay, J Woo, K H Or (Hong Kong); N Vetter (Cardiff). Victor Cummings, Joan Eagle, and S J Ogle also supported the review. J Baskett provided additional information and T K Kong identified a relevant trial.

Correspondence to: Dr Forster a.forster@leeds.ac.uk

Funding: NHS Executive Northern and Yorkshire Region, Stroke Association.

Competing interests: None declared.

27 3 1999 318 fakevolumedoi 7187 fakeDOI World Wide Web Usability Fake Supplement Title 837 841 837-838, 840-841 Research Unit of the Royal College of Physicians and British Geriatric Society Wildflowers of the Washington Area 2002 Lippman, Ltd. Bethesda, MD 0-23-8675-309, includes a CD-ROM, $19.95 (Used 12.50 when available)
29 1 1999
Copyright © 1999, British Medical Journal 1999

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article is available from http://www.harmreductionjournal.com/content/1/1/5 How to Make a Mother in Five Easy Steps

Objective

To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people.

Design

Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials).

Subjects

2867 elderly people.

Main outcome measures

Death, institutionalisation, disability, global “poor outcome,” and use of resources.

Results

Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or “poor” outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care.

Conclusions

Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable.

Key messages

The benefits of geriatric day hospital care have been controversial for many years

This systematic review of 12 randomised trials comparing a variety of day hospitals with a range of alternative services found no overall advantage for day hospital care

Day hospitals had a possible advantage over no comprehensive care in terms of death or poor outcome, disability, and use of resources

The costs of day hospital care may be partly offset by a reduced use of hospital beds and institutional care among survivors

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Introduction

Geriatric day hospitals developed rapidly in the United Kingdom in the 1960s as an important component of care provision. The model has since been widely applied in several Western countries. Day hospitals provide multidisciplinary assessment and rehabilitation in an outpatient setting and have a pivotal position between hospital and home based services. Although there is considerable descriptive literature on day hospital care,1 concern has been expressed that evidence for effectiveness is equivocal and that day hospital care is expensive.2 We therefore undertook a systematic review of the randomised trials of day hospital care.

Methods

The primary question addressed was whether older patients attending a day hospital would experience better outcomes than those receiving alternative forms of care. We anticipated considerable heterogeneity in both the intervention and control services and so specified key subgroup comparisons before reviewing the trials.

Inclusion criteria

We set out to identify all relevant controlled clinical trials of geriatric day hospital care. A day hospital was defined as an outpatient facility where older patients attend for a full or near full day and receive multidisciplinary rehabilitation in a health care setting.3 Trials evaluating social day centres, other types of day hospitals such as those for patients with dementia or psychiatric conditions, and single condition day hospitals were excluded.

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Table 3

Patient costs for institutional care at the end of scheduled follow up

Year | Cost per patient
--- | ---
1997 | $8,250
2000 | $31,400
2003 | $125,600

Numbers of patients receiving institutional care at the end of scheduled follow up and use of hospital beds among those allocated to day hospital or alternative services

Institutional care |  | Bed use (days)
--- | --- | ---
Patients | Patients | Odds ratio |  | Patients | Patients
Control group | Day hospital | Control | Odds ratio (95% CI) |  | Day hospital | Control
Comprehensive care (5 trials) | 151/597 | 159/584 | 0.91 (0.70 to 1.19) |  | 20.5 | 21.4
Domiciliary care (4 trials) | 20/216 | 19/227 | 1.61 (0.30 to 8.55) |  | 7.7 | 11.1
No comprehensive care (3 trials) | 37/411 | 66/403 | 0.50 (0.26 to 0.96) |  | 11.2 | 11.7
Total | 208/1224 | 244/1214 | 0.77 (0.52 to 1.13) |  | 15.0 | 16.4

Data not available for 1 trial.

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Additional material

Supplementary PDF file supplied by authors.

Search strategy

We searched for relevant published and unpublished papers up to January 1997. Our search strategy included Medline, SIGLE (System for Information on Grey Literature in Europe), BIDS (Bath Information and Data Services), CINAHL (Cumulative Index to Nursing and Allied Health), and the Cochrane Library. Key search terms included day hospital, day care, ambulatory care, and outpatient clinic. We also searched Index Medicus, British and international dissertation abstracts, conference abstracts (Society for Research in Rehabilitation, British Geriatrics Society), bibliographies of known trials, and other relevant articles and books. We publicised our work through presentations at geriatric symposia and by contacting authors of previous articles on day hospital care.

Background: The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale, scored 0 (no disability) to 100. The main purpose of this study was to assess the longitudinal construct validity of the DASH among patients undergoing surgery. The second phase purpose was to quantify self-rated treatment effectiveness after surgery.

Study appraisal and extraction of data

We selected outcomes to reflect a previous definition of the purpose of day hospital care: “to facilitate and prolong independent living for the elderly in the community.”4 Thus death, the need for institutional care, disability, hospital use, and resource use were selected as quantitative outcomes. In anticipation of incomplete data we also defined a global “poor outcome” comprising death or one of the following (in order of preference): resident in institutional care, severe disability at end of follow up, or deterioration in physical function during follow up. The research reports were independently assessed by three reviewers to establish eligibility, agree subcategories for the trials based on the treatment comparison, and to extract data.

Statistical methods

When possible, studies were analysed on an intention to treat basis. Surviving authors were contacted and asked to supply additional information when necessary. Patients who were lost to follow up or for whom outcome data were not available were excluded from the initial analysis. However, they were included in “best case” (all missing data in favour of day hospital care), neutral (all missing data recorded at the average event rate for the trial), and “worst case” (all missing data in favour of alternative care) sensitivity analyses.

We calculated odds ratios (with 95% confidence intervals) for the dichotomous outcomes using standard methods. A fixed effects approach5 was used initially and, if substantial heterogeneity was present, we confirmed this with a random effects approach.6 Outcomes were recorded at the end of scheduled follow up.

Results

We identified 703 abstracts, of which 687 were not relevant to the review or of descriptive studies. Sixteen evaluated a service fulfilling our definition of geriatric day hospital care. This analysis includes 12 trials which recruited 2867 subjects.7-18 Of the remaining four trials, one has just completed (J Baskett, personal communication); two did not include a random or quasirandom allocation procedure,19 20 and one was excluded because day hospital attendance was only one component of a complex multiple service intervention.21 Details of randomisation procedures, treatment schedules, and numbers of patients followed up are given on the BMJwebsite.

Deaths among patients receiving day hospital care or alternative services. Odds ratios of death by end of follow up were calculated by fixed effects model. Heterogeneity between trials is presented as ?2

Two columns identifying patient deaths for those with hospital care versus alternative services

Multidisciplinary outpatient rehabilitation was available at all the day hospital sites. Comparison groups comprised comprehensive elderly care (a range of inpatient, outpatient, and domiciliary geriatric medical services)9 10 12 13 15; domiciliary care (therapy provided in the patient’s home11 14 16 or day centre18); and no comprehensive elderly care (patients who were eligible for, but not referred to, existing services).7 8 17 For the trial by Gladman et al,16 only patients in the health care of the elderly strata have been included as the random treatment allocation of these patients included day hospital care.

Patient characteristics

One study was run by the Department of Veterans Affairs in the United States and was exceptional in that the sample was 96% male.15 In all trials the mean age of participants was at least 65 years and usually over 70 years. Three trials14 16 17 recruited only stroke patients, but the rest had a mixed population. Most patients had significant disability on a variety of scales.

Outcome data

Details on deaths were published, or provided on request, for all trials. Information about institutionalisation was published in only four studies7 9 13 16; additional data were provided by the authors for a further six studies.11 12 14 15 17 18 Data were also available concerning some aspect of disability (11 trials) and use of hospital beds (12 trials).

No significant differences in numbers of deaths occurred between patients attending day hospitals and those receiving any of the alternative services (fig 1). The pooled odds ratio for death was 1.02 (95% confidence interval 0.82 to1.26). There was no significant heterogeneity between the results of individual trials or categories of trials.

Figure 2 shows that overall there was no significant difference between day hospital and alternative forms of care in preventing death or a “poor” outcome at final follow up (odds ratio 0.90, 0.71 to 1.14; random effects model). However, patients attending day hospitals were less likely to have poor outcome than those receiving no comprehensive care (0.72, 0.53 to 0.99; P<0.05).

Odds of death or poor outcome in patients receiving day hospital care or alternative services (random effects model). Heterogeneity between trials is presented as ?2

Comparison of death ratios among poor receiving hospital care versus alternative services

Sensitivity analyses

Sensitivity analyses indicated that excluding trials with uncertain or insecure randomisation procedures would not substantially affect our conclusions.8 10 12 Data were missing on death for 155 (6%) patients and on death or poor outcome for 174 (7%). Best case and worst case sensitivity analyses include significant benefit (P<0.001) or harm (P<0.05) from day hospital care. The most plausible (neutral) sensitivity analysis suggested no effect on death (odds ratio 1.02, P>0.05) or death and poor outcome (0.92, P>0.2).

Disability

Eleven of the trials included a standardised measurement of activities of daily living,8-18 but seven different measures were used which could not be combined in a statistical summary. Seven trials8 11 12 14 16-18 provided data on 905 survivors (data missing for 65, 7%) whose disability scores were monitored during follow up (fig 3). Overall, day hospital patients had a similar chance as controls of suffering deteriorating function (1.11, 0.68 to 1.80; random effects model) but tended to have better outcomes than those receiving no comprehensive care (0.61, 0.38 to 0.97; P<0.05).

Deterioration in activities of daily living among survivors allocated to day hospital care or alternative services (random effects model). Heterogeneity between trials is presented as ?2

Survivors’ daily activity and deterioration with hospital care versus alternative services

Use of resources

Institutional care

Eleven trials provided information about the number of patients requiring institutional care at the end of follow up. Overall, there was a trend towards fewer day hospital patients requiring long term (median follow up 12 months) institutional care than those receiving alternative services (table) and the difference was significant in comparison with no comprehensive care.

Numbers of patients receiving institutional care at the end of scheduled follow up and use of hospital beds among those allocated to day hospital or alternative services

| Institutional care |  | Bed use (days)
--- | --- | --- | ---
Control group | Day hospital | Control | Odds ratio (95% CI) |  | Day hospital | Control
Comprehensive care (5 trials) | 151/597 | 159/584 | 0.91 (0.70 to 1.19) |  | 20.5 | 21.4
Domiciliary care (4 trials) | 20/216 | 19/227 | 1.61 (0.30 to 8.55) |  | 7.7 | 11.1
No comprehensive care (3 trials) | 37/411 | 66/403 | 0.50 (0.26 to 0.96) |  | 11.2 | 11.7
Total | 208/1224 | 244/1214 | 0.77 (0.52 to 1.13) |  | 15.0 | 16.4

Data not available for 1 trial.

P<0.05 (random effects model).

Use of hospital beds

Average hospital bed use per patient recruited could be calculated for all the trials, but a measure of variance could not be obtained and therefore we cannot report confidence intervals. The table shows a small reduction in bed use by day hospital patients across all trials (15.0 v 16.4 days).

Costs

Eight trials compared treatment costs, only two of which included costs of nursing home care.10 15 Six reported that day hospital care was more expensive than the comparison treatment,8 9 15 18 22 23 and two trials reported that the costs were similar.10 17

Discussion

Geriatric day hospitals have several functions, but rehabilitation has been regarded as most important1 and was the focus for this systematic review. We selected outcomes to reflect a definition of the core purpose of a geriatric day hospital.4 We used a predetermined definition of day hospital care3 and identified and categorised comparison services before collecting and analysing data. We excluded day hospitals for patients with specific conditions such as mental illness, dementia, or rheumatoid arthritis.

Limitations of the review

The main limitations of our review lie in the 30 years over which the trials were done, during which health and social care policies will inevitably have changed, and in the multinational location of the studies. Nevertheless, our data provide the best evidence available on which to judge the effectiveness of day hospitals.

A further problem is the limitations of the trials themselves, in particular the lack of statistical power resulting from small, heterogeneous trials. This raises the possibility of false positive and false negative results. Furthermore, the amount of missing outcome data adds uncertainty to most of our conclusions.

Publication bias remains a possibility, but our search strategy was extensive and included contacting authors of papers on day hospital care around the world. Many of the authors were able to provide unpublished additional information. A funnel plot analysis24 did not show any major evidence of missing data.

Findings

A big problem was that most trials compared day hospital care with an alternative “active” control. Only three trials7 8 17 used a comparison group of patients who received neither comprehensive care nor domiciliary rehabilitation. Compared with patients receiving no comprehensive care, patients attending day hospitals had less functional deterioration and institutional care and a small reduction in average hospital bed use. However, there was considerable loss to follow up in these three trials.

When day hospital services were compared with comprehensive elderly care (integrated inpatient, outpatient, and domiciliary services), the outcomes were largely similar. One interpretation is that day hospitals are comparable with an alternative service for which there is considerable evidence of effectiveness.25 However, the question arises whether day hospitals provide additional benefits when other comprehensive elderly care services are already in place. Our systematic review does not directly address this question.

We focused on a few specified outcomes, but many other important outcome domains, including patient preference and instrumental daily living activities, could not be examined as these outcomes were not widely available. It was also difficult to determine a summary statistic for disability because different measurement instruments were used and analysed in different ways. Moreover, commonly used measures of disability may be insensitive to change in the outpatient setting of a day hospital.26 This may explain why six trials reported no significant difference in disability outcome between day hospital and comparison services. Future trials should incorporate measures of intrumental activities of daily living as a more relevant and sensitive outcome.

Our analysis suggests that attending day hospital may reduce patients’ use of hospital and institutional care resources. However, costing studies need to balance any possible savings with the direct costs of day hospital care. Several studies have drawn attention to the expense of day hospital services.22 23 For six of the eight trials reporting cost information, day hospital care was more expensive than the alternative treatment.

On the whole, the trials we included took a pragmatic design approach and attempted to address a broad question of overall efficacy of day hospitals. Given the diversity of patients attending day hospitals and the corresponding diversity of interventions used, future trials need to be large multicentre trials or should examine more focused questions.

The authors gratefully acknowledge the contributions of the following individuals ...

An expanded version of this review has been submitted for publication in the Cochrane Library.

Appendix

Sudden deaths among patients receiving day hospital care rather than in-home care

Two columns identifying patient deaths for those with hospital care versus in-home care

Odds of death or poor outcome in patients among patients receiving day hospital care rather than in-home care

Comparison of death ratios among poor receiving hospital care versus in-home treatment

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Abbreviations

Abbreviation Expansion
F

female

gnty

genotype

M

male

the

specific article

a

non-specific article used with words beginning in consonants

an

non-specific article used with words beginning in vowels

Acronyms

Abbreviation Expansion
NIH

National Institutes of Health

XML

Extensible Markup Language

Research Unit of the Royal College of Physicians and British Geriatric SocietyGeriatric day hospitals: their role and guidelines for good practice 1994 London RCP National Audit OfficeNational health service day hospitals for elderly people in England 1994 London HMSO Siu AL Morishita L Blaustein J Comprehensive geriatric assessment in a day hospitalJ Am Ger Soc 1994 42 fakevolumedoi 1094 1099 1094-1096, 1098-1099 http://www.mulberrytech.com Fake DOI Donaldson C Wright KG Maynard AK Hamill JD Sutcliffe E Day hospitals for the elderly: utilisation and performanceCommunity Med 1987 9 B27 Peto R Fake Role Why do we need systematic overviews of randomized trials?Stat Med 1987 6 233 240 DerSimonian R Laird N Meta-analysis in clinical trialsControlled Clin Trials 1986 7 177 188 Woodford-Williams E McKeon JA Trotter IS Watson D Bushby C The day hospital in the community care of the elderlyGerontology Clinic 1962 4 241 256 Weissert W Wan T Livieratos B Katz S Effects and costs of day-care services for the chronically ill: a randomized experimentMedical Care 1980 18 567 584 6772889 Tucker MA Davison JG Ogle SJ Day hospital rehabilitation-effectiveness and cost in the elderly: a randomised controlled trialBMJ 1984 289 1209 1212 Cummings V Kerner JF Arones S Steinbock C Day hospital service in rehabilitation medicine: an evaluationArch Phys Med Rehabil 1985 66 86 91 Vetter NJ Smith A Sastry D Tinker GDay hospital pilot study report 1989 Cardiff Department of Geriatrics, St David’s Hospital Pitkala K Winell K Tilvis RS Effects of geriatric day hospital care for home care patientsArch Gerontol Geriatric 1991 suppl 2 51 54 Eagle DJ Guyatt GH Patterson C Turpie I Sackett B Singer J Effectiveness of a geriatric day hospitalCan Med Assoc J 1991 144 699 704 Young JB Forster A The Bradford community stroke trial: results at six monthsBMJ 1992 304 1085 1089 Branch LG Adult day health care evaluation studyMedical Care 1993 31(suppl) SS1 124 Gladman JRF Lincoln NB Barer DH A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital.J Neurol Neurosurg Psychiatry 1993 56 960 966 Hui E Lum CM Woo J Or KH Kay RLC Outcomes of elderly stroke patients day hospital versus conventional medical managementStroke 1995 26 1616 1619 Burch S, Longbottom J, McKay M, Borland C, Prevost T A randomised controlled trial of day hospital and day centre therapyClin Rehab (in press) Weiler PG Kim P Pickard LS Health care for elderly Americans: evaluation of an adult day health care modelMedical Care 1976 14 700 708 Sherwood S Morris JN Ruchlin HS Alternative paths to long-term care: nursing home, geriatric day hospital, senior center, and domiciliary care optionsAm J Public Health 1986 76 38 44 Skellie FA Mobley GM Coan RE Cost-effectiveness of community-based long-term care: current findings of Georgia’s alternative health services projectAm J Public Health 1982 72 353 358 Young J Forster A Day hospital and home physiotherapy for stroke patients: a comparative cost-effectiveness studyJ R Coll Phys Lond 1993 27 252 257 Gladman J Whynes D Lincoln N Cost comparison of domiciliary and hospital-based stroke rehabilitationAge Ageing 1994 23 241 245 Egger M Smith GD Schneider M Minder C Bias in meta-analysis detected by a simple, graphical testBMJ 1997 315 629 634 Stuck AE Siu AL Wieland GD Adams J Rubenstein LZ Comprehensive geriatric assessment: a meta-analysis of controlled trialsLancet 1993 342 1032 1036 Parker SG Du X Bardsley MJ Goodfellow J Cooper RG Cleary R Measuring outcomes in care of the elderlyJ R Coll Phys Lond 1994 28 428 433 27 Hughes TR Marton MJ Jones AC Functional discovery via a compendium of expression profiles. Cell 102 2000 109 126.

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Blanco Ernesto E Meade John C Richards William D Ophthalmic Ventures Surgical Stapling system US patent 4,969,591 1990 11 13 Fabdetti DV Golsmeier J Social workers as culture mediators in health care settings Health Soc Work 1988 Summer 13 3 fakeDOI in citation Social Work and Culture 171 179 Loewy Erich H. Ethical dilemmas in modern medicine 1986 Lewiston (NY) E. Mellen Press 343 Studies in health and human services; 8 International standard ISO 10993-10:2002(E): Biological evaluation of medical devices-Part 10: Tests for irritation and delayed-type hypersensitivity. Second. 2002-09-01 Black HR Evaluation of the elderly hypertensive Geriatrics 1989 10 44 Suppl B 15 19 Black HR Evaluation of the elderly hypertensive Geriatrics 1989 10 44 Suppl B 15 19 Miller Dorothy Mining XML 2002 Extreme Markup Languages Conference 2002 August 4, 2002 - August 9, 2002 Montreal, Canada Alexandria, VA IDEAlliance Massone L Borghi S Pestarino A Piccini R Gambini C Localisations palmaires purpurioques de la dermatitie herpetiforme Purpuric palmar sites of dermatitis herpetiformis Ann Dermatol Vernerol 1987 114 12 1545 1547 Hartmeier Winifried Immobilisierte Biokatalysstoren Immobilized biocatalysts 1988 Berlin Springer-Verlag 212 0-23-8675-309

Notes In Proof

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BR MED J International Journal of Health Geographics 0959-8138 British Medical Journal Fake Location 10092260a Treatment can be onerous for patient and doctor Seamark Clare J general practitioner a Hutchinson Margaret retired headmistress aHoniton Group Practice, Honiton, Devon EX14 2NY

Fake Notes Title

Correspondence to: C Seamark daseamark@msn.com

Competing interests: None declared.

Summer 2000 E27 http://www.ncemch.org/pubs/PDFs/ breastfeedingTIB.pdf Additional material

Supplementary PDF file supplied by authors.

07 2 2000
Copyright © 2000, British Medical Journal 2000

The development of genetic testing for disease has raised the problem of whether to test asymptomatic individuals....

We thank MH's family for their willingness to be involved in genetic testing ...

National Committee for Clinical Laboratory Standards Performance standards for antimicrobial disk susceptibility tests. Approved standard 2000 7th ed. Wayne, Pa National Committee for Clinical Laboratory Standards M2 A7 0959-8138 info@nccls.gov Lawrence Ruth A A review of the medical benefits and contraindications to breastfeeding in the United States [Internet] 1997 10 27 1:18 pm cited 2000 Apr 24 Arlington (VA) National Center for Education in Maternal and Child Health 40 Available from: http://www.ncemch.org/pubs/PDFs/ breastfeedingTIB.pdf