Mental health needs and services for severely troubled and troubling young people including young offenders in an N.H.S. region

Penal, social services, special education and health agencies in one National Health Service Region were screened for severely troubled and troublesome young people in need of mental health services. One hundred and sixteen detailed assessments were undertaken on young people: 57 in "penal" and 59 in "welfare" establishments. Little difference was found between those in these two types of setting except that the "penal group" were much more likely to have high levels of violent behaviour and to have had more changes of placement. The needs for mental health care greatly outstripped supply. As part of this overall neglect, 11 of 15 young people with serious mental illnesses and all 13 who had suffered sexual abuse in the sample were not receiving appropriate treatment. A tentative estimate of the size of the problem in the region yielded a rate of around 11.4 per million with very severe disorder but this is probably an under estimate. The effectiveness of treatment for the problems of these young people is discussed and a possible structure for a service is explored.

Prescribing patterns for asthma by general practitioners in six European countries

To assess the level of concordance with international consensus on asthma management, we compared primary care prescribing patterns for asthma in different European countries. A prospective study of prescription items with an associated diagnostic label of asthma in patient consultations with a total of 235 general practitioners (GPs) from Belgium, England, Ireland, Italy, Northern Ireland, Portugal, Scotland and Spain was performed. A total of 101,544 consecutive consultations were recorded in autumns 1994 and 1995 of which 3595 (3.5%) were for patients with asthma and 3243 (3.2%) were for patients receiving a prescription for asthma. Overall, asthma consultations varied from 1.8% in Italy to 5.8% in Ireland (mean 3.4%, SD 1.6). Prescribed inhaled medications for children varied from 72% of the total asthma prescriptions in Ireland and Portugal to 82% in Northern Ireland (mean 79%, SD 8.1) and for adults 55% in Italy to 85% in Spain (mean 70%, SD 10). Inhaled corticosteroid usage for adults varied from 14% in Italy to 31% in Northern Ireland (mean 24%, SD 6.4). For children, beta2-agonist use varied from 24% in Italy to 67% in Spain (mean 45%, SD 13). Despite publication of international guidelines for the management of asthma, inter-country prescribing practices vary considerably and could be improved. The frequency of use of asthma as a diagnostic label also varies markedly.

Are infants with orofacial clefts at risk for insecure mother-child attachments?

OBJECTIVE

Several risk factors in the early lives of children with clefts are believed to interfere with their development of secure attachments to parents; however, this possibility has rarely been studied empirically. This study compared 12- and 24-month attachment classifications of infants with cleft palate (CP), infants with cleft lip and palate (CLP), and a comparison group of unimpaired infants (COMP).

METHOD

Twenty-two CP infants, 24 CLP infants, and 61 matched COMP infants were assessed at 12 and 24 months of age in an urban children's hospital. At both visits, mothers and infants participated in the Strange Situation, which was videotaped and subsequently coded for patterns of attachment behavior.

RESULTS

CP infants displayed a lower rate of 12-month attachment security than infants in the CLP or COMP groups. By 24 months, no diagnostic group differences in attachment classification were found. Stable 12- to 24-month attachment classifications were less likely in the CP group (36.3%) than in the COMP (62.3%) group. CP infants who were insecure at 12 months were more likely to become secure by 24 months than were CLP or COMP group infants.

CONCLUSIONS

In contrast to previous theory and clinical speculation, the facial appearance of infants with CLP does not appear to affect the early mother-infant relationship adversely. The infancy period is marked by attachment instability for infants with CP, who demonstrated lower-than-expected rates of security at 12 months. However, these problems resolved in nearly all cases by 24 months of age. Most infants with clefts emerged from the first 2 years of life with secure maternal attachments.

Diaries of evidence-based tutors: beyond 'numbers needed to teach'

Interprofessional evidence-based health care courses have been held throughout the UK over the last few years, modelled on the approach used in McMaster University of using problem-based facilitated small-group formats to achieve the stated goals. Both delegates and tutors have been aware of the tensions which are inherent within these courses between: (a) the variation in learning cultures which is exhibited by the delegates and the effect this has on processes (i.e. the tension between the reductionist approach of bioscience and the more qualitative leanings of the applied and 'caring' disciplines); and (b) the conflict which arises between the goal of 'learning' applied healthcare biostatistics and the ability to leave the course with the skills to teach others. This qualitative study uses tutor-kept diaries to understand some of the tensions apparent to the teaching faculty during a week-long course in Wales, UK.

Predicting small-area health-related behaviour: a comparison of smoking and drinking indicators

Health-related behaviours are of central importance to health promotion and to the promotion of enhanced population health. In the UK, localised knowledge of the quantitative dimensions of health-related behaviours is traditionally attained by conducting a costly sample survey. Such surveys seldom generate reliable data at scales more local than that of the health authority, they also need to be repeated regularly. This paper outlines an alternative framework for generating statistics on small-area health related behaviours using routinely available data from the annual Health Survey for England (N = 17,000) and the decennial Population Census. Using a multilevel modelling approach nesting individuals within postcode sectors within health authorities, and focusing on the prevalence of smoking and 'problem' drinking, the paper comprises four sections: a consideration of the modelling strategy, a comparison of the smoking and drinking models, an outline of the estimation strategy, and the presentation and discussion of ward-level estimates of smoking and drinking behaviour for England. The paper concludes that the method is better at estimating smoking than drinking but that it offers a feasible, cheap and more informative alternative to the survey approach to the generation of information on smoking and drinking behaviour.

The mechanism of adverse events associated with terazosin: an analysis of the Veterans Affairs cooperative study

PURPOSE

We determined the mechanism of adverse events associated with alpha1-blockers for treating benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

We randomized 1,229 men with clinical BPH at 31 Veterans Affairs medical centers into equal treatment groups, including those who received placebo, terazosin, finasteride, and combined terazosin and finasteride therapy, respectively. Adverse events were captured at all study visits during our 1-year study. Our current review of adverse events is limited to patients randomized to the placebo and terazosin groups. We compared the incidence of orthostatic blood pressure change, postural symptoms and orthostatic hypotension in men who were normotensive and hypertensive at baseline, respectively. We also determined the association of changes in systolic blood pressure with the incidence of treatment related adverse events.

RESULTS

The treatment related rates of dizziness, asthenia, postural hypotension and syncope were 19%, 6%, 6% and 1%, respectively. Of these adverse events only postural hypotension was associated with orthostatic blood pressure changes. The incidence of asthenia, dizziness and postural hypotension was not significantly greater in patients with a systolic blood pressure decrease of 5 or greater and less than 5 mm. Hg, respectively.

CONCLUSIONS

Dizziness and asthenia are not associated with changes in blood pressure, suggesting that these treatment related adverse events associated with alpha1-blockers are not related to vascular events. Designing a subtype selective alpha1 antagonist that has less effect on blood pressure may not result in marked improvement in tolerability over commercially available alpha1-blockers.

Use of structural magnetic resonance imaging to predict who will get Alzheimer's disease

We used magnetic resonance imaging (MRI) measurements to determine whether persons in the prodromal phase of Alzheimer's disease (AD) could be accurately identified before they developed clinically diagnosed dementia. Normal subjects (n = 24) and those with mild memory difficulty (n = 79) received an MRI scan at baseline and were then followed annually for 3 years to determine which individuals subsequently met clinical criteria for AD. Patients with mild AD at baseline were also evaluated (n = 16). Nineteen of the 79 subjects with mild memory difficulty "converted" to a diagnosis of probable AD after 3 years of follow-up. Baseline MRI measures of the entorhinal cortex, the banks of the superior temporal sulcus, and the anterior cingulate were most useful in discriminating the status of the subjects on follow-up examination. The accuracy of discrimination was related to the clinical similarity between groups. One hundred percent (100%) of normal subjects and patients with mild AD could be discriminated from one another based on these MRI measures. When the normals were compared with the individuals with memory impairments who ultimately developed AD (the converters), the accuracy of discrimination was 93%, based on the MRI measures at baseline (sensitivity = 0.95; specificity = 0.90). The discrimination of the normal subjects and the individuals with mild memory problems who did not progress to the point where they met clinical criteria for probable AD over the 3 years of follow-up (the "questionables") was 85% and the discrimination of the questionables and converters was 75%. The apolipoprotein E genotype did not improve the accuracy of discrimination. The specific regions selected for each of these discriminations provides information concerning the hierarchical fashion in which the pathology of AD may affect the brain during its prodromal phase.

Death and deprivation: an exploratory analysis of deaths in the health and lifestyle survey

An analysis is undertaken of deaths of respondents in the UK- representative Health and Lifestyle Survey. The sample was originally interviewed in 1984/5 and followed initially until May 1997. Using multilevel logistic and Cox-proportional hazards models, the relationships between death and a wide range of social circumstances and behaviours is explored. It is found that place deprivation interacts with individual social class in accounting for variations in mortality. This is the case even when account is taken of personal health-related behaviour. There appears to be some evidence of a threshold relationship such that the differential effects of social class are only found at high-levels of deprivation. No statistically significant interactions are found for social and behavioural variables, for behavioural and place deprivation variables, and for social and place deprivation variables with the exception of social class. The study is deliberately exploratory and a wide range of models have been fitted which will be subject to more rigorous evaluation as the HALS death study proceeds.

Comparison of selected perceptual variables for backpacks with internal and external frames

Differences in perceptions of comfort, exertion, balance, and heart rate were investigated with two types of backpack. Subjects were 20 male volunteers (M age = 24.3 yr., SD: 3.6, M height = 180.02 cm, SD: 8.0, and M weight = 86.46 kg, SD: 14.84). Following oral briefing and practice trials, each subject was fitted at random with either an internal- or external-frame backpack containing 18.2 kg. By random, cross-over design, subjects completed a 30-m simulated hiking trial consisting of 16 separate obstacles designed to resemble actual off-trail hiking. Trials were conducted in a controlled environment with the walking intensity regulated by a metronome. Upon completion of each trial, the subjects rated the experience on perceived comfort, balance and stability, and rating of perceived exertion. Heart rate was recorded immediately prior to and following each trial. Analysis yielded a significant difference only on rating of perceived exertion in favor of the internal-frame backpack. Under limited circumstances, these data suggest that both types of backpacks provide similar comfort and balance and stability; however, internal frames in backpacks may reduce perceived exertion during short, demanding hikes.

Cognitive and psychomotor development of infants with orofacial clefts

OBJECTIVE

To compare at ages 3, 12, and 24 months the cognitive and psychomotor development of 29 infants with cleft lip and palate (CLP), 28 infants with cleft palate only (CPO), and a demographically matched comparison (COMP) group of 69 infants; to examine predictors of cognitive status at age 24 months in the cleft group.

METHODS

Infants were administered the Bayley Scales of Infant Development (BSID), mother-infant interactions were observed, and medical records were reviewed.

RESULTS

CLP and CPO groups scored lower than the COMP group on the BSID, but did not differ from one another. Cleft group infants scored lower than COMP group infants on BSID items assessing nonverbal and expressive language skills. Quality of maternal interaction predicted the 2-year Mental Development Index (MDI) scores of infants with clefts.

CONCLUSIONS

Infants with clefts show relative deficits in cognitive and psychomotor development. Cognitive deficits are apparent in nonverbal as well as verbal areas of performance.

Modified Aloe barbadensis polysaccharide with immunoregulatory activity

Aloe barbadensis polysaccharide was partially digested with cellulase and further purified by dialysis, stepwise ethanol precipitation, and size exclusion chromatography. Crude modified Aloe polysaccharide (MAP) activated macrophage cells and stimulated fibroblast growth. Under the same conditions, native Aloe barbadensis gel had no effect on macrophage activation. MAP prevented ultraviolet B (UVB) irradiation-induced immune suppression as determined by contact hypersensitivity (CHS) response in C3H/HeN mice. This in vivo activity was correlated with the activity of MAP to inhibit UVB irradiation-induced tumor necrosis factor alpha (TNF-alpha) release from human epidermoid carcinoma cells (KB cells). MAP with an average molecular weight of 80,000 Dalton (Da) contained mannose, galactose, and glucose in a ratio of 40:1.4:1.0. MAP was likely a linear, highly acetylated molecule.

Validity and reliability of a postoperative quality of recovery score: the QoR-40

Quality of recovery after anaesthesia is an important measure of the early postoperative health status of patients. We attempted to develop a valid, reliable and responsive measure of quality of recovery after anaesthesia and surgery. We studied 160 patients and asked them to rate postoperative recovery using three methods: a 100-mm visual analogue scale (VAS), a nine-item questionnaire and a 50-item questionnaire; the questionnaires were repeated later on the same day. From these results, we developed a 40-item questionnaire as a measure of quality of recovery (QoR-40; maximum score 200). We found good convergent validity between QoR-40 and VAS (r = 0.68, P < 0.001). Construct validity was supported by a negative correlation with duration of hospital stay (rho = -0.24, P < 0.001) and a lower mean QoR-40 score in women (162 (SD 26)) compared with men (173 (17)) (P = 0.002). There was also good test-retest reliability (intra-class ri = 0.92, P < 0.001), internal consistency (Cronbach's alpha = 0.93, P < 0.001) and split-half coefficient (alpha = 0.83, P < 0.001). The standardized response mean, a measure of responsiveness, was 0.65. The QoR-40 was completed in less than 6.3 (4.9) min. We believe that the QoR-40 is a good objective measure of quality of recovery after anaesthesia and surgery. It would be a useful end-point in perioperative clinical studies.

Safety and biological efficacy of a lipid-CFTR complex for gene transfer in the nasal epithelium of adult patients with cystic fibrosis

Gene transfer is an attractive option to treat the basic defect in cystic fibrosis. In a double-blind, placebo-controlled, rising-dose tolerance study in the nasal epithelium, we tested the safety and efficacy of a cationic liposome [p-ethyl-dimyristoylphosphadityl choline (EDMPC) cholesterol] complexed with an expression plasmid containing hCFTR cDNA. Eleven adult CF patients were studied in a protocol that allowed comparisons within individual subjects: vector and placebo were sprayed into alternate nostrils at intervals over 7 h. After dosing, vector-specific DNA was present in nasal lavage of all subjects for up to 10 days. There were no adverse events. The vector-treated epithelium did not exhibit a significant increase in CFTR-mediated Cl- conductance from baseline and was not different from the placebo-treated nostril: mean deltaCFTR Cl- conductance, mV +/- SEM, -1.6+/-0.4 vs -0.6+/-0.4, respectively. CFTR-mediated Cl- conductance increased toward normal during repetitive nasal potential difference measurements over the 3 days before dosing which influenced the postdosing calculations. No vector-specific mRNA was detected in the nasal epithelial scrape biopsies, although endogenous CFTR mRNA was detected in all subjects. We conclude that the lipid-DNA complex is safe, but did not produce consistent evidence of gene transfer to the nasal epithelium by physiologic or molecular measures.

Feather vs. non-feather bedding for asthma

BACKGROUND

Two recent epidemiological studies have reported that children using non-feather pillows suffered from more frequent episodes of wheeze than those using feather pillows

OBJECTIVES

To evaluate the efficacy of using feather bedding in the control of asthma symptoms.

SEARCH STRATEGY

The Cochrane Airways Group asthma clinical trials register, derived from MEDLINE, EMBASE and hand searching of major journals, was searched using the terms: feather OR bed* OR linen* OR pillow

SELECTION CRITERIA

Only randomised or controlled clinical trials were to be included.

DATA COLLECTION AND ANALYSIS

No trials met the inclusion criteria for the review.

MAIN RESULTS

126 abstracts were identified. Ten of these were identified as possibly meeting the entry criteria, but on review of the full paper not were suitable. The reasons for exclusion were: not a randomised trial (n=6); allocation of bedding type combined with another intervention (n=4).

REVIEWER'S CONCLUSIONS

Whilst recent epidemiological studies suggest that feather bedding is associated with less frequent wheeze than man-made fibre fillings, the evidence currently available is insufficient to assess the clinical benefits of feather bedding in the management of asthma.

Sequence and analysis of chromosome 4 of the plant Arabidopsis thaliana

The higher plant Arabidopsis thaliana (Arabidopsis) is an important model for identifying plant genes and determining their function. To assist biological investigations and to define chromosome structure, a coordinated effort to sequence the Arabidopsis genome was initiated in late 1996. Here we report one of the first milestones of this project, the sequence of chromosome 4. Analysis of 17.38 megabases of unique sequence, representing about 17% of the genome, reveals 3,744 protein coding genes, 81 transfer RNAs and numerous repeat elements. Heterochromatic regions surrounding the putative centromere, which has not yet been completely sequenced, are characterized by an increased frequency of a variety of repeats, new repeats, reduced recombination, lowered gene density and lowered gene expression. Roughly 60% of the predicted protein-coding genes have been functionally characterized on the basis of their homology to known genes. Many genes encode predicted proteins that are homologous to human and Caenorhabditis elegans proteins.

Prevalence of back, neck and shoulder problems in the inner city: implications for the provision of physiotherapy services in primary healthcare

BACKGROUND AND PURPOSE

More general practitioners are offering physiotherapy services within primary healthcare; however, this provision may result in increased demand. Resource allocation, based on previous patterns of consultation for musculoskeletal conditions, may be inadequate since the need for treatment in the community may not have been met in the past. Therefore the aim of this study was to determine the prevalence of back, neck and shoulder problems that had restricted normal activity for more than one week during the last year and which health professionals (if any) patients had consulted about their symptoms.

METHOD

A postal survey of 2400 adult patients selected at random from four general practices in Newcastle upon Tyne (600 from each practice).

RESULTS

A total of 1546 questionnaires were returned, a 64% response rate. Overall, 40% of respondants reported having at least one back, neck and/or shoulder problem. Back problems were most common (30%), followed by those with neck (21%) and shoulder (20%) problems. Approximately one-third of those with problems consulted no one, a further third consulted a general practitioner and only one in six consulted a physiotherapist.

CONCLUSIONS

There is a high prevalence of substantial back, neck and shoulder problems in the community and thus a wider provision of physiotherapy services within primary healthcare may be required to manage the considerable levels of potentially unmet need.

The Effect of Donor Cell Serum Starvation and Oocyte Activation Compounds on the Development of Somatic Cell Cloned Embryos

Two experiments, one comparing nuclear transfer (NT) embryo activation compounds, the other donor cell treatments, were conducted with a goal of identifying factors that improve the in vitro development of cloned bovine embryos. In experiment 1, 539 NT embryos were produced by combining serum starved bovine fetal fibroblasts with enucleated in vitro matured oocytes, activated with ionomycin, then randomly allocated to be incubated for 4 hours in either Butyrolactone-I (BL-I) or 6-dimethylaminopurine (DMAP). There was no significant difference in development to blastocyst or compact morula of fused embryos at Day 6.5 between BL-I and DMAP activated embryos (22.4% vs. 20.2%; p = 0.18). Karyotyping of 20 blastocysts and compact morula from each group determined that 65% of BL1 and 63% of DMAP embryos were diploid with the remainder mixoploid (2n + 4n). In Experiment 2, the development of 389 NT embryos reconstructed from either serum starved or serum fed fetal fibroblasts was assessed. More Day 7 blastocysts and compact morula developed in the serum starved group (34.5% vs. 18.8%; p = 0.008). To verify the viability of BL-I activated embryos, 10 blastocytes from experiment 2 were transferred into 4 recipient cows. Two morphologically normal fetuses, genetically identical to the original fetal cell line, were surgically recovered at day 45 of gestation. In summary, serum starvation of bovine fetal fibroblasts prior to NT significantly improved development to blastocyst. Additionally, we have shown that BL-I is a novel alternative compound for use in combination with ionomycin to activate NT embryos.

Distribution and seasonality of microbial indicators and thermophilic campylobacters in two freshwater bathing sites on the River Lune in northwest England

Two freshwater bathing sites, the Crook O'Lune and the University Boathouse, on the River Lune in the north-west of England, were monitored over a 2 year period for the faecal indicators, faecal coliforms and faecal streptococci, the pathogens, Salmonella and Campylobacter, and compliance with the EU Directive on Bathing Water Quality. Faecal indicator numbers showed no seasonal variation, with numbers in the bathing season similar to those in the non-bathing season. They were consistently above the EU Guideline and Imperative standards so that if the EU Bathing Water Quality Directive (76/160/EEC) were applied, neither site would comply. Faecal indicator numbers in the sediments were an order of magnitude higher than in the overlying water. Campylobacter numbers showed seasonal variation in the water with higher counts in winter than in the summer, although numbers were low. Higher numbers were found in the sediments but there was no seasonal variation. Analysis of various inputs showed that indicators and campylobacters came from a mixture of sources, namely a sewage treatment works, agricultural run-off, streams and mallards. Microbial numbers in the water at the Crook O'Lune, which is closer to the sources of pollution, were twice those at the Boathouse. In the sediments they were six to eight times higher. Faecal coliforms were all identified as Escherichia coli of which 80% were a single biotype. Faecal streptococci were all enterococci of which 55% were E. avium, 38% E. faecalis and 7% E. durans. Salmonella was not isolated from either the water column or the sediments. Campylobacters were mainly Camp. jejuni, followed by Camp. coli, UPTC and Camp. lari.

A confidential enquiry into certified asthma deaths in the North of England, 1994-96: influence of co-morbidity and diagnostic inaccuracy

To understand more fully the nature of events leading to asthmatic death, we conducted a confidential enquiry prospectively throughout 1994-96 among the surviving relatives and respective general practitioners of subjects whose deaths could be attributed to asthma, whether wholly or partly. We also reviewed relevant hospital records and autopsy reports, and we submitted all the gathered information to an enquiry panel for evaluation. The subjects were identified from death certificates issued in five districts of the Northern Health Region of England (population 1 million) on which asthma was recorded as the primary cause of death. The enquiry panel agreed that asthma had been a critical factor in causing death in only 33 of the 79 certified cases for which there were sufficient data. The level of concordance was substantially greater for subjects aged < 65 years (76%) than for those who were older (17%). In 16 of the 33 cases asthma alone appeared to be responsible for death, but in 17 cases a wide variety of additional, co-morbid, disorders appeared to have contributed. They included, during the 24 h preceding death, gastric aspiration, septicaemia, a single dose of a beta-blocker, the abuse of organic solvents or illicit drugs and possibly, an inadvertent exposure to horse allergen. More chronic causes of co-morbidity included ischaemic heart disease, chronic obstructive pulmonary disease (COPD), thoracic cage deformity and alcohol abuse. There were possible errors of judgement in two cases by the supervising physician (6%) and in three cases by the patient (9%). Poor compliance and psychosocial disruption probably exerted an additional adverse influence in nine cases (27%). We conclude: (1) that asthma death certification in subjects aged 65 years or more is very unreliable, (2) that for approximately half of the deaths in which asthma exerted a critical role there were critical co-morbid disorders and (3) that errors of judgement, poor compliance, or psychosocial disruption are likely to have exerted an additional adverse influence in an important minority of cases.

Immobilized lipoxygenase in a packed-bed column bioreactor: continuous oxygenation of linoleic acid

The continuous oxygenation of linoleic acid (LA) by immobilized lipoxygenase (LOX) was studied. Enzymatic oxidation was carried out in a recirculating packed column reactor using immobilized LOX as the stationary phase and LA as the substrate. The column, when packed with LOX immobilized in either a calcium alginate sol-gel matrix or a phyllosilicate sol-gel matrix, is equivalent to five continuous stirred tank reactors (CSTRs). The reactor cascade was calculated from the residence-time distribution for the reactor. Based on mass-balance calculations, a set of mathematical equations for predicting the concentration of oxygenated product generated in each CSTR was calculated. Product formation in the packed column reactor was simulated and results calculated with the model were compared with the experimental results. The data indicated that product yield (hydroperoxyoctadecadienoic acid, HPOD) increased asymptotically with reaction time. Experimentally, when the bioreactor was packed with calcium alginate sol-gel-immobilized LOX, an initial linear increase in HPOD production with time was observed, but reached a steady state. For the bioreactor packed with phyllosilicate sol-gel-immobilized LOX, initial HPOD production increased more rapidly but reached a lower steady-state concentration. From these data, a simple computer simulation model was developed to determine the process kinetics of this reactor design.

Glowing jellyfish, luminescence and a molecule called coelenterazine

Luminescence has assumed an important role in analytical biochemistry and molecular biology as an extremely sensitive method for determining the concentration of specific ions and molecules. The luminescent system of the jellyfish Aequorea victoria consists of the photoprotein aequorin, which contains the molecule coelenterazine as a prosthetic group and shows considerable potential in this area.