Developmental and etiological characteristics of children with sexual behavior problems: treatment implications

OBJECTIVE

Baseline data are reported on the demographics, psychological adjustment, victimization, and perpetration histories of 127 6- to 12-year-old children who have engaged in developmentally unexpected sexual behaviors. Information regarding the children's caregivers, and their extended families, is also presented. Data were collected during intake of the families into a longitudinal treatment outcome study.

METHOD

A comprehensive battery of psychometric devices and a structured interview were completed with 127 children with sexual behavior problems and their primary caregivers at intake to a treatment outcome study.

RESULTS

More than half of the children engaging in developmentally unexpected sexual behaviors had been abused both sexually and physically by more than two different perpetrators. One-third of the people who had maltreated these children were less than 18 years old. These children had acted out against an average of two other children. High levels of distress in the children and their caregivers were evident across a number of psychometric and historical variables.

CONCLUSION

Children with sexual behavior problems exhibited a number of functional impairments commonly associated with maltreatment, including learning and psychiatric disorders. Their caregivers and families manifested several characteristics that deter children's recovery from maltreatment, including an impaired attachment between parent and child. The scope of the children's problems requires that treatment extend beyond the therapist's office to include schools and other agencies or individuals with whom the child and families have regular contact.

The mechanism of inhibition of beta-oxidation by aspirin metabolites in skin fibroblasts from Reye's syndrome patients and controls

The effects of aspirin metabolites on beta-oxidation were studied in skin fibroblasts from eight typical Reye's syndrome (RS) patients and controls. RS patients' cells did not differ from controls in rates of palmitate oxidation or in the three component activities of the mitochondrial trifunctional enzyme (MTE), indicating no inherited beta-oxidation defect. Aspirin metabolites salicylate, hydroxyhippurate and gentisate, but not aspirin, directly inhibited palmitate oxidation in control and RS cells. RS cells were significantly more sensitive to inhibition than controls at 0.5 to 5 mM salicylate. Inhibition was concentration-dependent and reversible. Inhibition did not occur in fibroblasts lacking activity of the long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) activity of MTE. Salicylate was therefore inhibiting beta-oxidation at this step. Hydroxyhippurate and salicylate reversibly inhibited HAD activities in extracts of control and RS cells. Studies with pure short-chain HAD and LCHAD (MTE) showed hydroxyhippurate and salicylate were competitive inhibitors of the former but mixed (not competitive) inhibitors of the latter. Both compounds inhibited the combined, three-step, MTE reaction measured in the physiological direction. We conclude that (1) salicylate and hydroxyhippurate decrease beta-oxidation in intact cells by reversible inhibition of LCHAD activity of the MTE, and (2) beta-oxidation in RS cells is inherently more sensitive to inhibition by low concentrations of salicylate than controls.

Isolation and Characterization of Twelve Microsatellite Loci for Rockfish (Sebastes)

: We describe the first microsatellites for rockfishes in the diverse genus Sebastes. Clones containing microsatellites were isolated from the genomic library of a quillback rockfish, Sebastes maliger. Twelve microsatellites are characterized; six of these are polymorphic in quillback rockfish, and eight are polymorphic in at least one rockfish species on which they were tested. The number of alleles per variable locus ranged from 4 to 15 and averaged 6.8. The expected heterozygosities ranged from 0.38 to 0.79 and averaged 0.60 in these loci. These loci should prove valuable in studies examining species identification, population genetics, hybridization, paternity, kinship, and microsatellite evolution.

Predicting cytomegalovirus disease after renal transplantation: an artificial neural network approach

Outcome prediction is becoming increasingly important in medicine, but when a resource is scarce the need for accurate prediction becomes acute. Prediction based on biostatistical models has been in use for many years, but in areas such as renal transplantation their results have been disappointing. Recently however, there has been growing interest in the use of artificial neural networks for prediction. The creation of a large database containing high quality data on renal transplantation patients in Wales offers an ideal opportunity to research a new area viz., the ability of these techniques to accurately predict outcomes such as the appearance of disease in transplant recipients or the time to graft failure. This paper describes the use of neural networks to identify patients who risk the development of cytomegalovirus disease--a significant cause of mortality and morbidity in these patients. The neural networks we examined produced overall correct classifications well in excess of 80% in each of the two groups involved, diseased and non-diseased. These predictions are a considerable improvement on current methods and encourage the belief that renal transplantation data may respond well to analysis by neural networks.

Advance directives in a pediatric emergency department

Parents of children with terminal illnesses are not always present when a life-threatening event occurs. For many of these children, an advance directive specifying alternate code orders has been written by the parent or legal guardian (hereafter the use of parent is to be interpreted as parent/legal guardian) and the patient's attending physician. Implementing a pediatric advanced directive presents significant problems for emergency personnel if the parent is not present to identify the existence of the directive and interpret the contents in the context of the current medical crisis.

Follow-up of breast cancer in primary care vs specialist care: results of an economic evaluation

A randomized controlled trial (RCT) comparing primary-care-centred follow-up of breast cancer patients with the current standard practice of specialist-centred follow-up showed no increase in delay in diagnosing recurrence, and no increase in anxiety or deterioration in health-related quality of life. An economic evaluation of the two schemes of follow-up was conducted concurrent with the RCT Because the RCT found no difference in the primary clinical outcomes, a cost minimization analysis was conducted. Process measures of the quality of care such as frequency and length of visits were superior in primary care. Costs to patients and to the health service were lower in primary care. There was no difference in total costs of diagnostic tests, with particular tests being performed more frequently in primary care than in specialist care. Data are provided on the average frequency and length of visits, and frequency of diagnostic testing for breast cancer patients during the follow-up period.

Coitus-dependent family planning methods: observations from Bangladesh

Some coitus-dependent methods of family planning, such as withdrawal, periodic abstinence, and the condom, require male involvement for their use, and using these methods in combination has proved to be sensible. An investigation of why male and female respondents in a survey conducted in Bangladesh often gave conflicting answers about which methods they were currently using, particularly about "traditional" methods and condoms, showed that inconsistency in their reports arose because these methods are used in combination to such an extent that they are difficult to distinguish. In order to obtain reliable responses about these methods, a survey approach different from the long-established one is required.

Role of phosphatidylinositol 3,4,5-trisphosphate in regulating the activity and localization of 3-phosphoinositide-dependent protein kinase-1

3-Phosphoinositide-dependent protein kinase-1 (PDK1) interacts stereoselectively with the d-enantiomer of PtdIns(3,4,5)P3 (KD 1.6 nM) and PtdIns(3,4)P2 (KD 5.2 nM), but binds with lower affinity to PtdIns3P or PtdIns(4,5)P2. The binding of PtdIns(3,4,5)P3 to PDK1 was greatly decreased by making specific mutations in the pleckstrin homology (PH) domain of PDK1 or by deleting it. The same mutations also greatly decreased the rate at which PDK1 activated protein kinase Balpha (PKBalpha) in vitro in the presence of lipid vesicles containing PtdIns(3,4,5)P3, but did not affect the rate at which PDK1 activated a PKBalpha mutant lacking the PH domain in the absence of PtdIns(3,4,5)P3. When overexpressed in 293 or PAE cells, PDK1 was located at the plasma membrane and in the cytosol, but was excluded from the nucleus. Mutations that disrupted the interaction of PtdIns(3,4,5)P3 or PtdIns(4,5)P2 with PDK1 abolished the association of PDK1 with the plasma membrane. Growth-factor stimulation promoted the translocation of transfected PKBalpha to the plasma membrane, but had no effect on the subcellular distribution of PDK1 as judged by immunoelectron microscopy of fixed cells. This conclusion was also supported by confocal microscopy of green fluorescent protein-PDK1 in live cells. These results, together with previous observations, indicate that PtdIns(3,4,5)P3 plays several roles in the PDK1-induced activation of PKBalpha. First, it binds to the PH domain of PKB, altering its conformation so that it can be activated by PDK1. Secondly, interaction with PtdIns(3,4,5)P3 recruits PKB to the plasma membrane with which PDK1 is localized constitutively by virtue of its much stronger interaction with PtdIns(3,4,5)P3 or PtdIns(4,5)P2. Thirdly, the interaction of PDK1 with PtdIns(3,4,5)P3 facilitates the rate at which it can activate PKB.

The use and cost of HIV service provision in England in 1996. National Prospective Monitoring System (NPMS) Steering Group and NPMS Working Party on Costs

OBJECTIVE

The aim of the study was to measure the use and estimate the cost of HIV service provision in England.

DESIGN AND SETTING

Standardised activity and case-severity data were collected prospectively in 10 English HIV clinics (5 London and 5 non-London sites) for the periods 1 January 1996 to 30 June 1996 and 1 July 1996 to 31 December 1996 and linked to unit cost data. In total, 5440 patients with HIV infection attended during the first 6 months and 5708 during the second 6 months in 1996.

MAIN OUTCOME MEASURES AND RESULTS

The mean number of inpatient days per patient-year for patients with AIDS was 19.7 [95% confidence interval (CI): 13.7 to 25.7] for January to June and 20.8 (95% CI: 15.3 to 26.4) for July to December 1996. The mean number of outpatient visits for asymptomatic patients with HIV infection was 14.8 (95% CI: 11.9 to 17.6) and 13.3 (95% CI: 10.8 to 15.7) for the respective periods and 16.1 (95% CI: 13.21 to 18.97) and 15.7 (95% CI: 11.2 to 20.2), respectively, for patients with symptomatic non-AIDS (i.e. symptomatic patients with HIV infection but without AIDS-defining conditions). Substantial centre-to-centre variation was observed, suggesting that many clinics can continue the shift from an inpatient- to an outpatient-based service. Cost estimates per patient-year for HIV service provision for 1996 varied from 4695 Pounds (95% CI: 3769 Pounds to 5648 Pounds) for asymptomatic patients, to 7605 Pounds (95% CI: 6273 Pounds to 8909 Pounds) for symptomatic non-AIDS patients to 20,358 Pounds (95% CI: 17,681 Pounds to 23,206 Pounds) for patients with AIDS.

CONCLUSIONS

Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatient-related activity through the increased use of combination antiretroviral therapy will further shift service provision from an inpatient- to outpatient-based service and reduce costs per patient-year. The extent and duration of such effects are currently unknown. The long term effects of combination treatment on the morbidity and mortality patterns of individuals infected with HIV are also currently unknown, as are their implications on the use and cost of HIV service provision. Multicentre databases like the National Prospective Monitoring System (NPMS) will provide healthcare professionals with information to improve existing services and anticipate the impact of new developments.

Craniopharyngioma in children

PURPOSE

The treatment regimens at presentation and recurrence, the related morbidity, and survival rates were studied for children with craniopharyngioma who were treated at King Faisal Specialist Hospital & Research Center (KFSH&RC).

METHODS & MATERIALS

From 1975 to 1996, a total of 56 children younger than 18-years-old at diagnosis underwent treatment with surgery and/or radiotherapy for craniopharyngiomas at KFSH&RC. There was evidence that these patients had advanced disease at diagnosis; 36% of 51 patients whose visual status pretreatment was known were either blind or had major bilateral visual defects prior to treatment, and 36% of the 56 patients had diabetes insipidus. This report concentrates on 44 patients who had first definitive resection at KFSH&RC. Treatment policy was total resection if possible (17 patients), if not, subtotal resection (17 patients) or lesser procedures (10 patients). Five patients received postoperative irradiation after first definitive resection.

RESULTS

Ten-year-survival, and progression-free and event-free survival rates were 65%, 39%, and 29%, respectively. There were 9 postoperative deaths; 7 following the first procedure and 2 following resection for relapse, and 3 early deaths at home prior to relapse, following the first resection. None of the 22 patients who underwent less than total resection without postoperative radiation treatment were progression-free at 5 years, whereas the 5 patients who were irradiated remain progression-free.

CONCLUSION

A more selective approach to total resection, and the routine use of postoperative irradiation following lesser surgical procedures requires evaluation.

The distribution of health care costs and their statistical analysis for economic evaluation

OBJECTIVE

Where patient level data are available on health care costs, it is natural to use statistical analysis to describe the differences in cost between alternative treatments. Health care costs are, however, commonly considered to be skewed, which could present problems for standard statistical tests. This review examines how authors report the distributional form of health care cost data and how they have analysed their results.

METHOD

A review of cost-effectiveness studies that collected patient-level data on health care costs. To supplement the review, five datasets on health care costs are examined. Consideration is given to the use of parametric methods on the transformed scale and to non-parametric methods of analysing skewed cost data.

RESULTS

Since economic analysis requires estimation in monetary units, the usefulness of transformation-based methods is limited by the inability to retransform cost differences to the original scale. Non-parametric rank sum methods were also found to be of limited use for economic analysis, partly due to the focus on hypothesis testing rather than estimation. Overall, the non-parametric approach of bootstrapping was found to offer a useful test of the appropriateness of parametric assumptions and an alternative method of estimation where those assumptions were found not to hold.

CONCLUSIONS

Guidelines for the analysis of skewed health care cost data are offered.

Toll-like receptor-2 mediates lipopolysaccharide-induced cellular signalling

Vertebrates and invertebrates initiate a series of defence mechanisms following infection by Gram-negative bacteria by sensing the presence of lipopolysaccharide (LPS), a major component of the cell wall of the invading pathogen. In humans, monocytes and macrophages respond to LPS by inducing the expression of cytokines, cell-adhesion proteins, and enzymes involved in the production of small proinflammatory mediators. Under pathophysiological conditions, LPS exposure can lead to an often fatal syndrome known as septic shock. Sensitive responses of myeloid cells to LPS require a plasma protein called LPS-binding protein and the glycosylphosphatidylinositol-anchored membrane protein CD14. However, the mechanism by which the LPS signal is transduced across the plasma membrane remains unknown. Here we show that Toll-like receptor 2 (TLR2) is a signalling receptor that is activated by LPS in a response that depends on LPS-binding protein and is enhanced by CD14. A region in the intracellular domain of TLR2 with homology to a portion of the interleukin (IL)-1 receptor that is implicated in the activation of the IL-1-receptor-associated kinase is required for this response. Our results indicate that TLR2 is a direct mediator of signalling by LPS.

Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes

OBJECTIVES

To compare hospital at home care with inpatient hospital care in terms of patient outcomes.

DESIGN

Randomised controlled trial with three month follow up.

SETTING

District general hospital and catchment area of neighbouring community trust.

SUBJECTS

Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32).

INTERVENTIONS

Hospital at home care or inpatient hospital care.

MAIN OUTCOME MEASURES

Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures-chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care.

RESULTS

At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except those with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care.

CONCLUSIONS

Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern.

Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis

OBJECTIVES

To examine the cost of providing hospital at home in place of some forms of inpatient hospital care.

DESIGN

Cost minimisation study within a randomised controlled trial.

SETTING

District general hospital and catchment area of neighbouring community trust.

SUBJECTS

Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32).

INTERVENTIONS

Hospital at home or inpatient hospital care.

MAIN OUTCOME MEASURES

Cost of hospital at home scheme to health service, to general practitioners, and to patients and their families compared with hospital care.

RESULTS

No difference was detected in total healthcare costs between hospital at home and hospital care for patients recovering from a hip or knee replacement, or elderly medical patients. Hospital at home significantly increased healthcare costs for patients recovering from a hysterectomy (ratio of geometrical means 1.15, 95% confidence interval 1.04 to 1.29, P=0.009) and for those with chronic obstructive airways disease (Mann-Whitney U test, P=0.01). Hospital at home significantly increased general practitioners' costs for elderly medical patients (Mann-Whitney U test, P<0.01) and for those with chronic obstructive airways disease (P=0.02). Patient and carer expenditure made up a small proportion of total costs.

CONCLUSION

Hospital at home care did not reduce total healthcare costs for the conditions studied in this trial, and costs were significantly increased for patients recovering from a hysterectomy and those with chronic obstructive airways disease. There was some evidence that costs were shifted to primary care for elderly medical patients and those with chronic obstructive airways disease.

Pay in the British NHS: a local solution for a national service?

An important component of the reforms of the British National Health Service (NHS) has been devolution of a previously highly centralised pay bargaining system to the local provider level. As the wage bill is by far the single largest item of health care expenditure, the implications of this change may be far-reaching. This article surveys the available theory and evidence from an economic perspective. It reviews the development of pay determination mechanisms in the NHS and the extent to which local pay has been adopted since the reforms were introduced. It then considers the theory of local pay and general evidence on local pay variations in the UK, before turning to the available evidence on local labour markets in the health care sectors of the UK and USA. It concludes with a discussion of the policy and research implications of current developments on local pay bargaining in the NHS. In particular, it suggests that judgements over the success or failure of local pay bargaining will concern: first, whether the weakened monopsony position of the NHS at national level results in higher pay for the more powerful employee groups; second, whether fragmentation of bargaining weakens the negotiating and lobbying power of national trade unions and professional organisations; third, whether competition between providers leads to higher or lower costs; and fourth, whether any efficiency gains from local bargaining outweight the higher transaction costs involved.

Persistence of parvovirus B19 DNA in testis of patients with testicular germ cell tumours

Germ cell tumours (GCT) of the testis are the most common malignant tumours occurring in young adults. In view of the young age of patients, the increasing incidence of GCT and the overexpression of wild-type p53 observed in a majority of tumours, the possibility of the involvement of a virus in the development of this cancer was considered. Testicular GCT were analysed for the presence of cytomegalovirus and Epstein-Barr virus (EBV), which are known to cause overexpression of wild-type p53 protein, and parvovirus B19. The testicular tissue of 39 patients with testicular GCT and 12 patients with healthy testicular tissues was tested for presence of viral DNA by PCR. Neither cytomegalovirus nor EBV DNAs were detected in the 39 tumours analysed, but parvovirus B19 DNA sequences were demonstrated in the testicular tissue of 85% (33/39 cases) of patients with GCT. The sera of 16 of the 39 patients with GCT were tested for the presence of parvovirus B19 IgM and IgG. B19-specific IgG was detected in the sera of 11 patients (69%). Only one case was positive for parvovirus B19 IgM, which was also shown to have B19 genome sequences in the serum by PCR, indicating that in a majority of cases an acute B19 infection can be excluded as being the source of the B19 DNA sequences in the testis. B19 DNA could not be detected in normal testicular tissue and thus parvovirus B19 could play a role, direct or indirect, in the development of testicular GCT or have tropism for the tumour cells.

The use of out of hours health services: a cross sectional survey

OBJECTIVES

To determine the use and costs of the principal out of hours health services in Buckinghamshire.

DESIGN

Prospective cross sectional survey and cost description of patient contacts with out of hours services.

SETTING

Buckinghamshire during March and April 1995.

SUBJECTS

General practices, accident and emergency departments, ambulance services, and community nursing services.

MAIN OUTCOME MEASURE

Contacts with patients and cost of out of hours services.

RESULTS

438 patient contacts/1000 population/year were recorded at an annual incremental cost of between 4.6 m Pounds and 7.2 m Pounds (depending on the costing of general practitioner services), for a population of 660,000. Of these contacts, 21,649 (45%) were with general practitioners. Night time contacts with all services diminished sharply after 10 pm. General practitioners considered that 40% of contacts were unnecessary or could have waited until morning. Over 70% of contacts were for upper respiratory tract infections, earache, gastroenteritis, and other minor ailments. Nursing care was predominantly for elderly people, and 33% of nursing contacts were to supervise medication. Accident and emergency care was predominantely for young adults, especially men, and 41% of attendances were for medical conditions.

CONCLUSIONS

New models such as multidisciplinary primary care centres with telephone advice lines and triaging are required to ensure high quality, cost effective care that is responsive to the needs of both consumers and professionals.

Caregivers of children with sexual behavior problems: psychological and familial functioning

OBJECTIVE

This research examined demographic and functional characteristics of parents of children with sexual behavior problems.

METHOD

Families of 72 children with sexual behavior problems completed a structured interview and several psychometric devices at intake into a treatment outcome study.

RESULTS

As a group, caregivers manifested signs of a high level of life stress across a wide array of variables, including income, criminal arrest, family violence, sexual abuse, social support, modulation of emotion, and attachment to their child. Foster parents consistently reported significantly lower levels of stress than biological parents.

CONCLUSION

Parents and families of children with sexual behavior problems appear multiply entrapped. They are highly distressed and somewhat isolated. The data convincingly demonstrate that in order to maximize the efficacy of treatment for children with sexual behavior problems, parents must be centrally involved and receive services coordinated with those of their child. Group treatment may be advisable to foster formation of a network of peer support for caregivers of children with sexual behavior problems.

Wine tasting and dental erosion. Case report

A case of widespread dental erosion is reported in an individual who had worked in the wine industry for ten years. This occupation involved daily tasting of at least 20 wines, but often more. The erosion manifested as dental sensitivity with there being cervical erosion, occlusal pitting, and loss of enamel around restorations. The effect of immersing unerupted human teeth in white wine (pH 3.3) was examined with the scanning electron microscope, where marked surface changes had occurred after 24 hours of exposure.