An ethical approach to resolving value conflicts in child protection

Child protection professionals working in diverse societies are regularly faced with value conflicts. Recognising these, and resolving them in the best interests of children, is a task that requires child protection specialists to make complex judgements and decisions. In this paper the philosophical concepts of absolutism and relativism to child abuse are applied, and it explores how this approach has practical relevance to solving ethical dilemmas in child protection. Children's interests are best served by erring towards an absolutist approach to the diagnosis and recognition of maltreatment and towards a relativistic approach in determining how services respond to a harmful incident or situation. Absolutism and relativism are not alternatives, but part of a continuous process of recognising and negotiating ever-changing community, national and global norms. At the service level the dichotomy transpires into the need to be culturally competent in handling the conflicting needs, rights and values of children, families, communities and professionals, whilst retaining the skill of child advocacy.

Comprehensive analysis of common mitochondrial DNA variants and colorectal cancer risk

Several lines of evidence implicate mitochondrial dysfunction in the development of cancer. To test the hypothesis that common mtDNA variation influences the risk of colorectal cancer (CRC), we genotyped 132 tagging mtDNA variants in a sample of 2854 CRC cases and 2822 controls. The variants examined capture approximately 80% of mtDNA common variation (excluding the hypervariable D-loop). We first tested for single marker associations; the strongest association detected was with A5657G (P=0.06). Overall the distribution of association P-values was consistent with a null distribution. Next, we classified individuals into the nine common European haplogroups and compared their distribution in cases and controls. This analysis also provided no evidence of an association between mitochondrial variation and CRC risk. In conclusion, our results provide little evidence that mitochondrial genetic background plays a role in modifying an individual's risk of developing CRC.

Childhood socioeconomic circumstances and adult height and leg length in central and eastern Europe

BACKGROUND

Adult height and leg length have been shown to be positively associated with childhood socioeconomic circumstances in several studies in western populations. This study will determine whether similar associations are observable in settings with different social histories, and will assess whether adult leg length is more strongly associated than adult height.

METHODS

Random samples of men and women aged 45-69 years were taken from population registers in Novosibirsk (Russia), Krakow (Poland) and six towns of the Czech Republic, recruiting nearly 29,000 people. Participants completed a questionnaire that included questions regarding their mother's and father's education (not available in the Czech Republic) and ownership of several household items when they were 10 years old. Participants' standing and sitting heights were measured and from these an estimate of leg length was derived. Associations between indicators of childhood socioeconomic circumstances and anthropometric measures were analysed using linear regression.

RESULTS

Russian individuals were shorter and reported fewer household assets at the age of 10 years than Czech and Polish individuals. Parental education and household assets were strongly associated with each other and both were independently associated with height, leg length and trunk length. Height was associated with childhood circumstances more strongly than leg length. The associations of childhood circumstances with the leg/trunk ratio were weak and inconsistent.

CONCLUSION

In these urban populations in eastern Europe, adult height is associated with childhood conditions at least as strongly as leg length.

CASP8 variants D302H and -652 6N ins/del do not influence the risk of colorectal cancer in the United Kingdom population

Polymorphisms in CASP8 at 2q33.1 have been associated with the risk of developing cancer, specifically, the D302H variant (rs1045485) with breast cancer in the European population and the −652 6N ins/del promoter variant (rs3834129) with multiple tumours including colorectal cancer (CRC) in the Chinese population. We evaluated the relationship between −652 6N ins/del and D302H variants and risk of developing CRC in the UK population by genotyping 4016 cases and 3749 controls. Both variants showed no evidence of an association with risk of developing CRC (P=0.42 and 0.22, respectively). In contrast, the recently identified CRC susceptibility allele rs6983267 mapping to 8q24 was significantly associated with disease risk (P=8.94 × 10⁻⁸). It is thus very unlikely that variation in CASP8 defined by −652 6N ins/del or D302H influences the risk of CRC in European populations. The implications of our findings both in terms of population-specific effects and publication bias are discussed.

Characteristics of the m2000 automated sample preparation and multiplex real-time PCR system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae

We evaluated a new real-time PCR-based prototype assay for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae developed by Abbott Molecular Inc. This assay is designed to be performed on an Abbott m2000 real-time instrument system, which consists of an m2000sp instrument for sample preparation and an m2000rt instrument for real-time PCR amplification and detection. The limit of detection of this prototype assay was determined to be 20 copies of target DNA for both C. trachomatis and N. gonorrhoeae, using serially diluted linearized plasmids. No cross-reactivity could be detected when 55 nongonococcal Neisseria isolates and 3 non-C. trachomatis Chlamydia isolates were tested at 1 million genome equivalents per reaction. Concordance with the Roche Amplicor, BDProbeTec ET, and Gen-Probe APTIMA Combo 2 tests was assessed using unlinked/deidentified surplus clinical specimens previously analyzed with these tests. For C. trachomatis, concordance for positive results ranged from 93.7% to 100%, while concordance for negative results ranged from 98.2% to 100%. For N. gonorrhoeae, concordance for positive and negative results ranged from 91.4% to 100% and 99.3% to 100%, respectively. A workflow analysis of the prototype assay was conducted to obtain information on throughput under laboratory conditions. At 48 samples/run, the time to first result for both C. trachomatis and N. gonorrhoeae was 4.5 h. A total of 135 patient specimens could be analyzed in 8.9 h, with 75 min of hands-on time. This study demonstrated the technical and clinical feasibility of the new Abbott real-time PCR C. trachomatis/N. gonorrhoeae assay.

Benefits of interprofessional learning: an interprofessional MSc in child health

This article addresses interprofessional education (IPE) using a case study evaluating a multidisciplinary MSc course in child health. The participants felt that the nature of the course increased their interprofessional working skills and professional confidence. They described benefits, including new insights, a balanced variety of views, development of respect and equality between professionals, improved communication and a holistic approach to child health.

Clinical correlates of early medication adherence: West London first episode schizophrenia study

OBJECTIVE

Little is known about factors that mediate adherence with medication during the early stages of antipsychotic treatment in schizophrenia. This study sought to identify factors that may be associated with medication adherence in first-episode schizophrenia.

METHOD

In 101 patients, adherence was assessed along with potentially relevant variables, including attitudes toward medication, insight, substance misuse, side effects and psychopathology.

RESULTS

In a linear regression analysis, negative attitudes toward medication and a relative lack of insight contributed significantly towards poor adherence. Although poorly adherent patients had significantly higher scores on negative and disorganization syndromes, these did not contribute significantly towards adherence. Adverse medication side effects, subjective well-being and substance misuse showed no significant association with adherence.

CONCLUSION

At the initiation of drug treatment, attitudes toward medication and insight appear more relevant to medication adherence than side effects. Adherence appears to reflect a complex interaction of influences, which may change over time.

Prevalence of autistic spectrum disorder in children attending mainstream schools in a Welsh education authority

All mainstream primary schools in Cardiff were invited in July 1998 to participate in a prevalence survey of autistic spectrum disorder. Teachers of each class filled in a questionnaire based on ICD-10 criteria for autistic disorders. The Autism Spectrum Screening Questionnaire (ASSQ) was completed on children identified with problems identified by the questionnaire. A total of 11692 children born between 1 September 1986 and 31 August 1990 were screened: 234 (2%) children were identified as requiring an ASSQ; 151 of 234 (65%) ASSQs were returned. Of the 151, 60 children (52 male, 8 female; 40%) scored 22 or more. Their notes and the involved professionals were consulted. Thirty-five children, unknown to specialist services or with complex features, required additional assessment. Seventeen children (all male) were found to be on the autistic spectrum. When the overall rubric was disentangled we found a diverse population of affected children including a handful who did not fit easily into ICD-10 classification. Correcting for incomplete ascertainment we found a minimum prevalence of 20.2 out of every 10 000 (SE = 4.5) for autistic spectrum disorder in this population.

Evaluation of cultural competence and antiracism training in child health services

AIMS

To evaluate the acceptability and effectiveness of cultural competence and antiracism training to professionals providing services to ill or disabled children.

METHODS

Immediate post-training and retrospective questionnaire survey of trainees. Main outcome measures were acceptability; perceived relevance to practice; previous training in this area; perceived impact on professionals' confidence in providing care to diverse communities; and reported changes in behaviour and practice.

RESULTS

Cultural competence and antiracism training has been neglected in the health sector but is well received by professionals. It is a positive experience for trainees and perceived to be relevant to their practice. Appropriate and non-threatening training in cultural competence changes attitudes, behaviours, and practice, including promoting good practice in communication across linguistic and cultural differences.

CONCLUSIONS

Appropriate cultural competence and antiracism training is both effective and acceptable in child health services.

Heart defects and ocular anomalies in children with Down's syndrome

AIMS

To investigate whether ocular anomalies are associated with congenital heart defects in children with Down's syndrome.

METHODS

58 children with Down's syndrome were entered into a retrospective observational study. Children were assigned to heart defect groups based on medical records. Optometric tests had previously been carried out at the homes of the children.

RESULTS

A relation between congenital cardiac defects, myopia, and nystagmus was observed. Heart problems were not related to accommodative insufficiency, hyperopia, or strabismus.

CONCLUSION

In children with Down's syndrome heart defects were associated with both myopia and nystagmus.

Rapid determination of substrate specificity of Clostridium histolyticum beta-collagenase using an immobilized peptide library

The molecular basis of the substrate specificity of Clostridium histolyticum beta-collagenase was investigated using a combinatorial method. An immobilized positional peptide library, which contains 24,000 sequences, was constructed with a 7-hydroxycoumarin-4-propanoyl (Cop) fluorescent group attached at the N terminus of each sequence. This immobilized peptide library was incubated with C. histolyticum beta-collagenase, releasing fluorogenic fragments in the solution phase. The relative substrate specificity (k(cat)/K(m)) for each member of the library was determined by measuring fluorescence intensity in the solution phase. Edman sequencing was used to assign structure to subsites of active substrate mixtures. Collectively, the substrate preference for subsites (P(3)-P(4)') of C. histolyticum beta-collagenase was determined. The last position on the C-terminal side in which the identity of the amino acids affects the activity of the enzyme is P(4)', and an aromatic side chain is preferred in this position. The optimal P(1)'-P(3)' extended substrate sequence is P(1)'-Gly/Ala, P(2)'-Pro/Xaa, and P(3)'-Lys/Arg/Pro/Thr/Ser. The Cop group in either the P(2) or P(3) position is required for a high substrate activity with C. histolyticum beta-collagenase. S(2) and S(3) sites of the protease play a dominant role in fixing the substrate specificity. The immobilized peptide library proved to be a powerful approach for assessing the substrate specificity of C. histolyticum beta-collagenase, so it may be applied to the study of other proteases of interest.

Aging and physical fitness are more important than obesity in determining exercise-induced generation of GH

Exercise is a potent stimulus for GH secretion. Aging and obesity are associated with a diminution of GH secretion. We wanted to determine whether age or fat mass is more important in regulating the GH response to exercise. Four groups of healthy men were studied: seven lean young men [age, <40 yr; body mass index (BMI), <25 kg/m(2)], six overweight young men (age, <40 yr; BMI, >27.5), seven lean older men (age, >60 yr; BMI, <25), and 6 overweight older men (age, 60 yr; BMI, >27.5). The men performed a maximal exercise test. GH secretion was higher in the younger men than in the older men. Peak GH was higher in the older lean men than in the older overweight men. There was no difference between the young groups. Fitness correlated negatively with age and positively with peak GH. In young men, there was no relation between BMI, bioimpedance, or leptin and GH secretion. In contrast, in older men there was an inverse correlation between measures of fat mass and GH secretion. Age and physical fitness are more important than body fat in regulating exercise-induced GH secretion. These findings have important clinical implications if we are to prevent the frailty and morbidity associated with aging.

The health of children in refuges for women victims of domestic violence: cross sectional descriptive survey

OBJECTIVES

To describe the health and developmental status of children living in refugees for women victims of domestic violence and to investigate their access to primary healthcare services.

DESIGN

Cross sectional survey.

SETTING

Women's refugees in Cardiff.

PARTICIPANTS

148 resident children aged under 16 years and their mothers.

MAIN OUTCOME MEASURES

Completeness of records on the child health system (register of all children that includes data on the child's health) for named health visitor, named general practitioner, and immunisation uptake; satisfactory completion of child health surveillance; Denver test results for developmental status; Rutter test scores for behavioural and emotional problems; reports of maternal concerns.

RESULTS

148/257 (58%) children living in refugee between April 1999 and January 2000 were assessed. Child health system data were incorrect (general practitioner and/or address) or unavailable for 85/148 (57%) children. Uptake of all assessments and immunisations was low. 13/68 (19%) children aged <5 years had delayed or questionable development on the Denver test, and 49/101 (49%) children aged 3-15 years had a Rutter score of >10 (indicating probable mental health problems). Concerns were expressed by mothers of 113/148 (76%) children. After leaving the refuge, 22 children were untraceable and 36 returned home to the perpetrator from whom the families had fled.

CONCLUSIONS

The children had a high level of need, as well as poor access to services. Time spent in a refuge provides a window of opportunity to review health and developmental status. Specialist health visitors could facilitate and provide support, liaison, and follow up.

Identification of vaccine candidate antigens from a genomic analysis of Porphyromonas gingivalis

Porphyromonas gingivalis is a key periodontal pathogen which has been implicated in the etiology of chronic adult periodontitis. Our aim was to develop a protein based vaccine for the prevention and or treatment of this disease. We used a whole genome sequencing approach to identify potential vaccine candidates. From a genomic sequence, we selected 120 genes using a series of bioinformatics methods. The selected genes were cloned for expression in Escherichia coli and screened with P. gingivalis antisera before purification and testing in an animal model. Two of these recombinant proteins (PG32 and PG33) demonstrated significant protection in the animal model, while a number were reactive with various antisera. This process allows the rapid identification of vaccine candidates from genomic data.

Lesions in gshA (Encoding gamma-L-glutamyl-L-cysteine synthetase) prevent aerobic synthesis of thiamine in Salmonella enterica serovar typhimurium LT2

Thiamine pyrophosphate is an essential cofactor that is synthesized de novo in Salmonella enterica serovar Typhimurium and other bacteria. In addition to genes encoding enzymes in the biosynthetic pathway, mutations in other metabolic loci have been shown to prevent thiamine synthesis. The latter loci identify the integration of the thiamine biosynthetic pathway with other metabolic processes and can be uncovered when thiamine biosynthesis is challenged. Mutations in gshA, encoding gamma-L-glutamyl-L-cysteine synthetase, prevent the synthesis of glutathione, the major free thiol in the cell, and are shown here to result in a thiamine auxotrophy in some of the strains tested, including S. enterica LT2. Phenotypic characterization of the gshA mutants indicated they were similar enough to apbC and apbE mutants to warrant the definition of a class of mutants unified by (i) a requirement for both the hydroxymethyl pyrimidine (HMP) and thiazole (THZ) moiety of thiamine, (ii) the ability of L-tryosine to satisfy the THZ requirement, (iii) suppression of the thiamine requirement by anaerobic growth, and (iv) suppression by a second-site mutation at a single locus. Genetic data indicated that a defective ThiH generates the THZ requirement in these strains, and we suggest this defect is due to a reduced ability to repair a critical [Fe-S] cluster.

Determination of up-to-date vaccination status for preschool-aged children: how accurate is manual assessment conducted by paraprofessional staff?

BACKGROUND

Accurate identification of underimmunized children is needed to determine which children need vaccination. Previous studies have found the accuracy of manually determining the immunization status from a personal vaccination record to be low (<50%).

OBJECTIVE

To determine the accuracy of manual immunization status assessment for preschool-aged children.

SUBJECTS AND SETTING

Children </=32 months old (n = 21 263) seen over 1 year at 12 women, infants, and children (WIC) sites in San Diego, California. Age at evaluation was between 0 and 24 months.

METHODS

Paraprofessional immunization specialists conducted manual immunization status assessment using the WIC client's personal vaccination record. Immunization status as recorded in the WIC record was compared with computerized assessment (the gold standard).

MEASURES AND RESULTS

For all patient encounters, 29 078 (80%) of 36 368 were assessed correctly; manual assessment outcome was not recorded in the WIC record for 2171 (6%) of encounters. Accuracy varied by WIC site (range: 70%-90%). The sensitivity at correctly identifying an underimmunized child per encounter was 53.6%; the specificity at correctly identifying a fully vaccinated child per encounter was 89. 4%. The 3 most common vaccines that were incorrectly assessed in identifying an underimmunized child were Haemophilus influenzae type b (43%), hepatitis B (37%), and diphtheria-tetanus toxoids and (cellular or acellular) pertussis vaccine (24%). Children with no outcome as recorded in the WIC record were 5 times as likely to be up-to-date.

CONCLUSIONS

Manual immunization assessment was specific but only moderately sensitive at identifying underimmunized children. Thus, many underimmunized children will by missed but only 10% of children will be referred inappropriately.