[Spiral computerized tomography diagnosis of abdominal seat belt injuries in children]

Seat belt injury (s.b.i.) arises from not properly applied seat belt in case of car accidents. The importance of spiral CT for the diagnosis of s.b.i., especially of hidden traumatic lesions, will be demonstrated. Our experience includes 9 children in the age of 4 to 13 years suffering from life-threatening s.b.i. After life-saving treatment we took a spiral CT (Somatom plus S): first spiral CT, 10 mm slice thickness, without contrast medium (c.m.) and second spiral CT, 5 mm slice thickness, start delay 35-45 s after a large volume of c.m. Of these, 8 of 9 children survived. Besides bruising signs head injuries, and knee joint lesions in 4 of 9 cases, a combination of ruptured duodenum, ruptured liver or spleen, and chance fractures of the spine was found which is typical for s.b.i. In the remaining 5 cases, two of the lesions were combined. Rupture of the small bowel was manifested mainly as the discrete finding of free air or inhomogeneous ascites with a high density (bowel contents mixed with blood). Not only the emergency doctor but also the radiologist should take into account the complexity of seat belt injuries. Spiral CT is the imaging method of choice in the case of polytraumatic children.

Vegetative state and responses to sensory stimulation: an analysis of 24 cases

A meta-analysis was performed on data from 24 single-case experimental studies evaluating the immediate effects of sensory stimulation treatment on patients in vegetative state following traumatic brain injury. Response to treatment was evaluated by time sampling behaviour pre- and post-treatment, and examining for changes in behaviour that suggested increased arousal. In this analysis the relative effectiveness of different treatment protocols was examined. The effects of variables such as age, gender and time since injury on magnitude of behaviour change was examined; also whether there was a relationship between response to treatment and outcome in terms of whether patients emerged from vegetative state or not. Analyses showed that multimodal stimulation produced greater behavioural changes than unimodal stimulation, and the use of personally salient stimuli in multimodal stimulation the greatest changes of all. Age and gender both showed effects on the magnitude of the behaviour change, but time since injury did not. Patients who did not emerge from the vegetative state were no less likely that those who did to produce statistically significant changes in behaviour in response to treatment. The paper includes a discussion of general issues concerning vegetative state.

Preventive services for breast and cervical cancer in U.S. office-based practices

BACKGROUND

This study was undertaken to examine patterns of delivery of preventive services for breast and cervical cancer and the bundling of several preventive services.

METHODS

Data from the National Ambulatory Medical Care Survey on visits by women ages > or = 45 years to office-based physicians during 1989 and 1990 were analyzed for delivery of clinical breast examination, mammography, breast self-examination counseling, pelvic examination, and Pap smear.

RESULTS

An estimated 38.7 million office visits included one or more preventive services for breast and cervical cancer (46.7 visits per 100 women per year). Visits that included clinical breast examination, Pap smear, and mammography together were largely provided by obstetricians and gynecologists, less by general/ family practice and general internal medicine physicians, and rarely by subspecialists. Twenty-two percent of these visits were periodic preventive visits, lowest for subspecialists and highest for general internists. Major sources of payment included insurance and personal resources at younger ages and Medicare at ages > or = 65.

CONCLUSIONS

The periodic preventive visit has received only limited acceptance by physicians who provide preventive care for adult women. Payment for preventive visits changes with age and may affect the appropriate provision of services.

Behavioural differences between patients who emerged from vegetative state and those who did not

This paper reports on a meta-analysis of behavioural data gathered using single case research methodology, while evaluating the immediate effects of a treatment (sensory stimulation) on 24 individuals diagnosed as being in vegetative state following trauma. The data derived from time sampling have been used to compile measures of behavioural change in response to environmental events, which are referred to as arousal profiles. In addition to this, interviews were conducted regularly to elicit structured observations from the nursing staff concerning behavioural changes that they had observed. The subjects were divided into two groups according to whether they had emerged from vegetative state or not at the time the meta-analysis commenced. Statistically significant differences were found between the outcome groups in terms of modal arousal profile characteristics; one profile type was characteristic only of those that emerged. The two groups could also be differentiated by the mean recovery curves derived from the interview data. Behavioural differences between the outcome groups have been found which are detectable while the patients are in vegetative state. These findings have prognostic potential.

Constructing arousal profiles for vegetative state patients--a preliminary report

Arousal profiles are a method that we have developed for using data derived from time sampling to examine how behaviours such as the frequency with which the eyes are observed open, and the frequency of spontaneous movements, vary in the periods immediately before and immediately after sensory stimulation treatment. We believe changes in such behaviours reflect changes in arousal. The use of this new technique is illustrated with examples from a pilot study using data from 15-day treatment blocks, gathered for 10-minute periods immediately before and after sensory stimulation treatment from three patients using single-case research methods. The patients were diagnosed as being in vegetative state following traumatic brain injury. The possible significance of the differing characteristics of the profiles is discussed.

Effects of case management after severe head injury

OBJECTIVES

To examine the effects of early case management for patients with severe head injury on outcome, family function, and provision of rehabilitation services.

DESIGN

Prospective controlled unmatched non-randomised study for up to two years after injury.

SETTING

Four district general hospitals and two university teaching hospitals, each with neurosurgical units, in east central, north, and north east London and its environs.

SUBJECTS

126 patients aged 16-60 recruited acutely and sequentially after severe head injury. All received standard rehabilitation services in each of the six hospitals and districts: case management was also provided for the 56 patients admitted to three of the hospitals.

MAIN OUTCOME MEASURES

Standard measures of patients' physical and cognitive impairment; disability and handicap; and affective, behavioural, and social functioning and of relatives' affective and social functioning. Relatives' perception of burden; changes in patients' and relatives' housing, financial, vocational, recreational, and medical needs; and ongoing requirements for care and support; and the amount and type of paramedical input provided were assessed with structured questionnaires.

RESULTS

For a given severity of injury, case management increased the chance and range of contact with inpatient and outpatient rehabilitation services. However, duration of contact was not increased by case management, and there was no demonstrable improvement in outcome in the case managed group. Any trends were in favour of the control group and could be accounted for by group differences in initial severity of injury.

CONCLUSIONS

Widespread introduction of early case management of patients after severe head injury is not supported, and early case management is not a substitute for improvement in provision of skilled and specialist rehabilitation for patients.

Prescription and nonprescription drug use among black and white community-residing elderly

OBJECTIVES

To examine and compare concomitants of prescription and nonprescription drug use of Black and White community-dwelling elderly.

METHODS

Information on prescription and nonprescription drug use, demographic and health characteristics, and use of health services was obtained from a probability-based sample of Black (n = 2152) and White (n = 1821) community-resident elderly in the Piedmont area of North Carolina. Descriptive statistics were calculated. Linear regression, in which sample weights and design effects were taken into account, was used for the final models.

RESULTS

For prescription drug use, 37% and 32% of the variance was explained for Whites and Blacks, respectively (6% and 5% for nonprescription drugs). Health status and use of medical services were the strongest predictors of prescription drug use for both races (with Medigap insurance also important for Whites and Medicaid important for Blacks). Demographic characteristics and self-assessed health were significant factors in the use of nonprescription drugs. Race independently predicted use of both types of drugs but explained only a small proportion of the variance.

CONCLUSIONS

Health status and use of health services are importantly related to prescription drug use. Non-prescription drug use is difficult to explain.

Testicular cancer

Although testicular cancer accounts for approximately 1% of all male malignancies, it has a significant impact on the social, economic, and emotional status of the young population in which it occurs. TSE is the best available tool for early detection of testicular cancer. Only 15 to 20 years ago, testicular cancer was often fatal because of the rapidity of metastasis to the lungs and other vital organs. Because of progress in surgical technique and chemotherapy, it is today one of the most curable cancers. The use of serum markers and early diagnosis and treatment are of great importance in the management of testicular cancer.

Linkage analysis of maturity-onset diabetes of the young (MODY): genetic heterogeneity and nonpenetrance

We have analyzed the inheritance of maturity-onset diabetes of the young (MODY) on chromosome 20 in a large multigeneration family, the R.-W. family, and in two other MODY families. Of the four branches of the R.-W. pedigree which have been studied, two have documented early onset of non-insulin-dependent diabetes mellitus (NIDDM), while there is no evidence of early onset in the other two branches. The early-onset branches have apparently inherited the same D20S16 allele from the affected parent, while another D20S16 allele was inherited in the two branches without evidence of early onset. A test for homogeneity, the M-test, using the results of two-point linkage analysis with D20S16 indicates heterogeneity between early- and late-onset branches of the R.-W. family (P less than or equal to .014). In addition, analysis strongly suggests that MODY as expressed in the EDI and WIS families is unlinked to loci on chromosome 20 (P less than or equal to .018-.004). Comparable results are seen when the data are analyzed by the HOMOG program. Three polymorphic loci-D20S16, D20S17, and ADA--show no recombination with the MODY locus when two-point linkage analysis is used in the early-onset branches of the family. The multipoint lod score in the early-onset branches of the R.-W. family is 10.16, with the most likely location being between D20S4 and D20S17. Multipoint linkage analysis using the CHROMPICS option of the program CRI-MAP has been used to follow inheritance of the MODY disease locus. This analysis has identified two cases of possible nonpenetrance in the early-onset branches of the family (odds of at least 156:1), as determined by the appearance of apparent isolated double crossovers at the MODY locus in these unaffected individuals.

Knowledge and beliefs about cancer in a socioeconomically disadvantaged population

Americans living in poverty experience a higher incidence of and greater mortality from cancer than the nonpoor. At least 50% of the difference in mortality is believed to be due to delay in diagnosis, although risk-promoting lifestyles and behaviors also contribute to decreased survival. A potential exacerbating factor among the poor is inadequate information and knowledge about cancer and its treatment. Interviews were conducted with 128 cancer patients from a socioeconomically disadvantaged population to assess knowledge of cancer and its treatment and to evaluate care-seeking behaviors. Results indicated that although patients relied primarily on their physicians for information about their disease and treatment, a number of misconceptions regarding cancer existed in this population. Notably, nearly 50% of the patients surveyed either denied or did not know that smoking was related to the development of cancer. Additionally, patients frequently reported inappropriate care-seeking behaviors when asked to respond to a series of common disease-related signs or symptoms. These findings suggest that misinformation and misconceptions regarding cancer and its treatment among patients in this sample may contribute to inappropriate care-seeking behaviors.

[Foot problems in chronic polyarthritis: shoe advice and foot care]

Inflammatory alterations of the feet due to rheumatoid arthritis very often reduce the patient's quality of life. We present the pathogenetic mechanisms and discuss practicable and efficient prophylactic and therapeutic methods. A method recently developed by our occupational therapist for placing foot pads correctly in shoes is described.

Group environment and group interaction in psychiatric assessment meetings

This study examines two aspects of psychiatric assessment meetings: staff perceptions of group social climate, and staff verbal interaction. An Experimental group using a novel format was compared with two groups using a Traditional format. Group environment was measured by the Group Environment Scale (GES). Staff verbal interaction was rated both in terms of discussion content and distribution of discussion time among the categories of Chair, Keyworker, and Others. Changes in group environment were found on four out of ten GES subscales: in the Experimental meetings Expressiveness and Independence both increased, while Leader Control, and Anger & Aggression decreased. Content of discussion remained largely unchanged, but there was a marked shift in the distribution of discussion time towards Keyworkers and away from the Chair.

[Treatment of otherwise incurable tumor diseases in childhood using whole-body hyperthermia and chemotherapy]

Conventional methods of treatment having failed in 17 children (aged 9/12 to 16 5/12 years) with incurable solid malignant tumours underwent whole-body hyperthermia (41.8-42.0 degrees C, for 2-3 h), hyperglycaemia (20-25 mmol/l) and polychemotherapy. Five children had neuroblastoma (stage 4), three Wilm's tumour (stage 4 or 5, unfavourable histology), five skeletal sarcoma with metastases, three inoperable malignant liver tumour, and one brainstem tumour of unknown histology. Whole-body hyperthermia was induced by extracorporeal blood warming in an haemodialysis apparatus under neuroleptic analgesia, thermistors measuring the temperature in the oesophagus, rectum, trachea and skin. There were on average four treatment sessions (between one and ten, total 58), a week apart. The result could be assessed in 12 children: one persisting complete remission (19 months-metastasising renal rhabdoid tumour), eight partial or incomplete remissions, and three nonresponders (osteogenic sarcoma; Ewing sarcoma; brainstem tumour). If the risk can be satisfactorily judged the method is useful and of bearable toxicity. The results point to a high antitumour effectiveness of combined hyperthermia and chemotherapy.

Regulation of physicians' office laboratories. The Idaho experience

Timely availability of reliable test results enhances the office practitioner's ability to provide high-quality care that is personally satisfying to patients. Modern technology allows physicians to have such timely information available through test analyses performed in an office laboratory. Studies of physicians' office laboratories in Idaho found the performance, initially, to be unacceptably variable for many hematology, urinalysis, clinical chemistry, and microbiology tests. State regulation, requiring each office laboratory to comply with quality assurance guidelines and to participate in a proficiency testing program, resulted in a marked improvement in the proficiency level of office laboratory testing in Idaho. With the increasing dispersion of clinical laboratory technology, it is essential that standards of practice for the office laboratory be developed that ensure, within reasonable limits, the reliability of test information used in patient care. If widespread acceptance of such standards cannot be developed with a voluntary approach, states should consider regulation of office laboratories within their jurisdiction. Compliance with standards of practice, voluntarily or as a result of regulation, should promote quality performance in the office laboratory and allow the physician to use confidently the timely test information in dealing with diagnostic and management problems in patient care.

Does bacteremia occur during flexible sigmoidoscopy?

Up to 10% of patients may have bacteremia after rigid sigmoidoscopy. The aim of our study was to determine the frequency of bacteremia accompanying flexible sigmoidoscopy. Blood samples for aerobic and anaerobic cultures were obtained before, during, and after flexible sigmoidoscopy in 100 patients who were examined a mean distance of 49.5 cm, range 15-60 cm, after a bowel preparation of two Fleet enemas. In one patient, a transient bacteremia with Streptococcus intermedius was documented and was attended by no associated clinical manifestations. This organism has been previously isolated from patients with endocarditis, peritonitis, emphysema, and hepatic and appendiceal abscesses. There was no association in our study with bacteremia and such factors as length of bowel examined and duration of procedure, the presence of bowel pathology, performance of endoscopic biopsies, liver disease, and portal hypertension or poor bowel preparation. We conclude that the extremely low incidence of significant bacteremia with flexible sigmoidoscopy may be related to the smaller diameter of the instrument and provides further support for the routine use of flexible rather than rigid sigmoidoscopy.

Variability in the Proteus syndrome: report of an affected child with progressive lipomatosis

In 1983 the Proteus syndrome was delineated by Wiedemann et al. [12]. We report a 10-month-old girl, a further child affected by the new syndrome. The typical signs are macrodactyly, hemihypertrophy, pigmented nevi, hyperkeratosis, and subcutaneous hamartomatous tumours. Our patient shows an aggressive lipomatosis on the trunk and local relapses after surgical interventions in the regions involved. Histology of the adipose tissue showed considerable anisocytosis and increased cell volume.