A simple method of evaluating patients' perceptions of their treatment and care

Surveys of patient satisfaction have become commonplace in mental health services. However, questions about the appropriateness of "satisfaction" as a concept and its use as an approach to evaluating the quality of service provision remain as pertinent as ever. Although surveys of patients of mental health services routinely generate high levels of apparent satisfaction, noncompliance with treatment and medication continues to be a major difficulty in psychiatric care. To evaluate services properly, there is a need to access patients' dissatisfaction to determine whether it is a more valid indicator of quality of services and a better predictor of noncompliance. However, a method that is not time consuming and costly is also required. The authors introduce a new patient evaluation tool, "Your Treatment and Care," which requires patients to report on their direct experience of care according to a set of principles of good practice. The tool forms part of a broader package for obtaining patients' views of their own problems, need for care, quality of care received, and health and social outcomes. The authors also report the results of a survey using this tool. Responses of 75 patients of a psychiatric hospital in the United States are presented and compared with results from a similar survey in the United Kingdom. The comparisons show striking differences in patients' perceptions of quality of treatment and care, both within each population and across clinical contexts.

Implementation of an outcomes management model of treatment

The author provides an overview of the new approach to clinical documentation and outcomes assessment and management that is being implemented at The Menninger Clinic as part of a larger effort to systematically study and refine the treatment provided by the Clinic. The scientific, clinical, economic, and regulatory context within which these changes are being made is discussed. Key aspects of the flow of clinical documentation, treatment planning, care recording, and the multifaceted assessment of outcomes and treatment satisfaction are summarized. This article explicates a model for the integration of the processes of clinical information recording with clinical measurement as a means for scientifically evaluating whole clinical systems and their treatment protocols and outcomes.

The How Are You? scale: a quality-of-life outcomes measure for routine practice

The How Are You? scale, a quality-of-life outcomes self-report measure to be completed by patients, was developed to address the concerns of the mental health consumer movement. Specific concerns included using less technical language in assessing mental health problems and developing a collaborative dialogue between clinician and patient. The How Are You? scale is a user-friendly instrument that allows patients to be actively involved in their assessment and treatment process. To implement the How Are You? scale into a recording and measurement system, its psychometric properties were assessed using two samples: (1) An employee group from The Menninger Clinic was used to assess internal consistency and stability, and (2) a patient group from The Menninger Clinic was used to assess known-group and discriminant validity, as well as sensitivity to change. The How Are You? scale was found to have good internal consistency and stability and good known-group and discriminant validity. It was also found to be sensitive to change. Although data continue to be collected at The Menninger Clinic, initial indications are that the How Are You? scale is a psychometrically sound outcomes measurement tool.

Which treatments help? The patient's perspective

In an effort to determine which specific aspects of treatment might account for patient satisfaction, the authors developed the Components of Treatment Questionnaire. This measure, which was administered to 500 adult inpatients along with the Client Satisfaction Questionnaire (CSQ-8; Larsen, Attkisson, Hargreaves, and Nguyen, 1979), asked patients to assess the helpfulness of their treatment. Convinced that patient input is pertinent to program design, the authors later surveyed 46 patients on treatments that they perceived as helpful and would like to receive. Respondents identified individual relationships and problem-focused therapies as the most helpful aspects of treatment.

Preventing bacterial adhesion onto surfaces: the low-surface-energy approach

Good-quality coatings prepared from poly(methylpropenoxyfluoroalkylsiloxane)s or poly(perfluoroacrylate)s are capable of inhibiting the bacterial colonisation of surfaces.

A rapid quantitative assay of intact paracetamol tablets by reflectance near-infrared spectroscopy

Near-infrared (NIR) reflectance spectroscopy was used to determine rapidly and non-destructively the content of paracetamol in bulk batches of intact Sterwin 500 mg tablets by collecting NIR spectra in the range 1100-2500 nm and using a multiple linear regression calibration method. The developed NIR method gave results comparable to the British Pharmacopoeia 1993 UV assay procedure, the standard errors of calibration and prediction being 0.48% and 0.71% m/m, respectively. The method showed good repeatability, the standard deviation and coefficient of variation for six NIR assays on the same batch on the same day being 0.14 and 0.16% m/m, respectively, while measurements over six consecutive days gave 0.31 and 0.36% m/m, respectively. Applying the calibration to a parallel test set gave a mean bias of -0.22% and a mean accuracy of 0.45%. The developed method illustrates how the full potential of NIR can be utilised and how the ICH guidelines which recommend the validation of linearity, range, accuracy and precision for pharmaceutical registration purposes can be applied. Duplicate determinations on bulk batches could be performed in under 2 min, allowing the potential use of the method on-line for real time monitoring of a running production process.

Pion conformal radiation of prostate cancer: results of a randomized study

PURPOSE

To compare the efficacy of pion radiation therapy with conventional external beam photon therapy, for the treatment of locally advanced stage T3/4, N0, M0 adenocarcinoma of the prostate.

METHODS AND MATERIALS

Two hundred seventeen eligible patients were randomly allocated to either photon or pion therapy. No adjuvant hormone therapy was used.

RESULTS

Median follow-up was 42 months (range 2-90). Acute bladder toxicity was worse in the pion arm, p = 0.2, but other acute toxicity did not differ. Late grade 2 toxicity was significantly less in the pion arm (29% at 5 years versus 48%, p = 0.002), but late grade 3 or 4 toxicity did not differ. Clinical local control was not significantly different between treatment arms (64% after 5 years with photons, 56% with pions, p = 0.6). Cause-specific and overall survival also did not differ (p = 0.7). There was a significant delay in time to first failure in the photon arm, largely as a result of decreased biochemical relapse, p = 0.01. A multivariate analysis is presented.

CONCLUSION

Pion therapy was well tolerated, with increased acute toxicity and significantly decreased late tissue injury. This contrasts with the late toxicity observed with higher LET particle therapy such as neutron therapy. No improvement in local control with pion therapy was observed.

Survival of brown kiwi exposed to 1080 poison used for control of brushtail possums in Northland, New Zealand

All 35 radio-tagged adult brown kiwi (Apteryx mantell i) survived at least three months after being exposed to 1080 poison (sodium monofluoroacetate) during a brushtail possum (Trichosurus vulpecul a) control operation; 22 birds were exposed to 1080 in pollard baits at a loading of 0.15% w/w, and 13 birds were exposed to 1080 presented in jam baits, at a loading of 0.08% w/w. A radio-tagged juvenile was killed by a predator 2.5 months after being exposed to jam baits. In the three months after the 1080 operation, the weights of adult kiwi in the poisoned area were no different from those in neighbouring bush patches. No traces of 1080 were found in six eggs collected from the poisoned area. From subsequent captures of birds, all 35 birds are known to have survived at least six months after the operation, and 33 (94%) survived one year after exposure to 1080 baits. These results are consistent with other similar, but smaller, studies of the survival of radio-tagged kiwi exposed to 1080 poison in pollard or carrot baits. We conclude that possum-control operations using green-dyed and cinnamon-lured pollard or jam baits laced with 1080 poison pose a very low risk to brown kiwi through accidental primary or secondary poisoning, or by starvation due to a diminished supply of large invertebrates.

The onset of coulomb explosions in polyatomic molecules

With the development of high intensity femtosecond lasers, the ionisation and dissociation dynamics of molecules has become an area of considerable interest. Using the technique of femtosecond laser mass spectrometry (FLMS), the molecules carbon disulphide, pyrimidine, toluene, cyclohexanone and benzaldehyde are studied with pulse widths of 50 fs in the near infrared (IR) wavelength region (790 nm). Results are presented and contrasted for laser beam intensities around 10(15) and 10(16) W cm(-2). For the lower intensities, the mass spectra yield dominant singly charged parent ions. Additionally, the appearance of doubly charged parent ions is evident for carbon disulphide, toluene and benzaldehyde with envelopes of doubly charged satellite species existing in these local regions. Carbon disulphide also reveals a small triply charged component. Such atomic-like features are thought to be a strong fingerprint of FLMS at these intensities. However, upon increasing the laser intensity to approximately 10(16) W cm(-2), parent ion dominance decreases and the appearance of multiply charged atomic species occurs, particularly carbon. This phenomenon has been attributed to Coulomb explosions in which the fast absorption of many photons may produce transient highly ionised parent species which can subsequently blow apart. Copyright 1999 John Wiley & Sons, Ltd.

Uniform molecular analysis using femtosecond laser mass spectrometry

The potential of femtosecond laser time-of-flight mass spectrometry (FLMS) for uniform quantitative analysis of molecules has been investigated. Various samples of molecular gases and vapours have been studied, using ultra-fast ( approximately 50 fs) laser pulses with very high intensity (up to 1.6 x 10(16) Wcm(-2)) for non-resonant multiphoton ionisation/tunnel ionisation. Some of these molecules have high ionisation potentials, requiring up to ten photons for non-resonant ionisation. The relative sensitivity factors (RSF) have been determined as a function of the laser intensity and it has been demonstrated that for molecules with very different masses and ionisation potentials, uniform ionisation has been achieved at the highest laser intensities. Quantitative laser mass spectrometry of molecules is therefore a distinct possibility. Copyright 1999 John Wiley & Sons, Ltd.

Quantification of paracetamol in intact tablets using near-infrared transmittance spectroscopy

Production batch samples of paracetamol tablets and specially prepared out-of-specification batches covering the range 90-110% of the stated amount (500 mg) were analysed by the BP official UV assay and by NIR transmittance spectroscopy. NIR measurements were made on 20 intact tablets from each batch, scanned five times each (10 min measurement time per batch) over the spectral range 6000-11,520 cm-1. An average spectrum was calculated for each batch. Partial least squares (PLS) regression models were set up using a calibration set (20 batches) between the NIR response and the reference tablet paracetamol content (UV). Various pre-treatments of the spectra were examined; the smallest relative standard error of prediction (0.73%) was obtained using the first derivative of the absorbance over the full spectrum. Only two principal components were required for the PLS model to give a good relationship between the spectral information and paracetamol content. Applying this model to the validation set (15 batches) gave a mean bias of -0.08% and a mean accuracy of 0.59% with relative standard deviations of 0.75 and 0.44%, respectively. The proposed method is non-destructive and therefore lends itself to on-line/at-line production control purposes. The method is easy to use and does not require a knowledge of the mass of the tablets.

Extreme hypoventilation reduces ventilator-induced lung injury during ventilation with low positive end-expiratory pressure in saline-lavaged rabbits

OBJECTIVE

To compare the degrees of ventilator-induced lung injury caused by two ventilation protocols.

DESIGN

Randomized trial.

SETTING

University animal laboratory.

SUBJECTS

Sixteen New Zealand white rabbits.

INTERVENTIONS

After five sequential saline lung lavages, eight pairs of anesthetized rabbits were allocated randomly to receive either of two ventilation protocols for 4 hrs during neuromuscular blockade. Both groups received 3 cm H2O of positive end-expiratory pressure and 100% oxygen. Control group animals received an estimated tidal volume of 12 mL/kg, an inspiratory time of 0.7 sec, and a ventilatory rate adjusted for a PaCO2 of 35 to 45 torr (4.7 to 6 kPa). Study group animals were ventilated through an intratracheal catheter, with inspiratory time of 1.5 secs, ventilatory rate of 20 breaths/min, and peak inspiratory pressure of 4 to 8 cm H2O, adjusted to maintain PaCO2 at 150 to 250 torr (20 to 33 kPa).

MEASUREMENTS AND MAIN RESULTS

Arterial blood gases were measured every 30 mins. After 4 hrs, a final lung lavage was performed. Physiologic parameters, cell counts and protein concentration in the final lavage, and lung histology were compared between groups. The alveolar-arterial oxygen tension gradient was higher in the study group over the first 1.5 hrs, but the time profile showed significantly (p = .001) greater improvement in the study group. After 4 hrs, the mean alveolar-arterial oxygen tension gradient was lower in the study group (94 torr [12.5 kPa] vs. 201 torr [26.8 kPa]). The increase in neutrophil count from the initial to the final lung lavage was lower in the study group (0.27 x 10(7) cells/L vs. 2.01 x 10(7) cells/L, p = .037), as was the absolute value of the neutrophil count in the final lavage (1.33 x 10(7) cells/L vs. 3.02 x 10(7) cells/L, p = .04). The median hyaline membrane score was lower in the study group (0.5 vs. 3.0) but the difference was not statistically significant.

CONCLUSION

These findings suggest that a very low tidal volume reduces ventilator-induced lung injury in saline-lavaged rabbits during ventilation at low lung volume.

Approximate standard errors and confidence intervals for indices of positive and negative agreement

Indices of positive and negative agreement for observer reliability studies, in which neither observer can be regarded as the standard, have been proposed. In this article, it is demonstrated by means of an example and a small simulation study that a recently published method for constructing confidence intervals for these indices leads to intervals that are too wide. Appropriate asymptotic (i.e., large sample) variance estimates and confidence intervals for the positive and negative agreement indices are presented and compared with bootstrap confidence intervals. We also discuss an alternative method of interval estimation motivated from a Bayesian viewpoint. The asymptotic intervals performed adequately for sample sizes of 200 or more. For smaller samples, alternative confidence intervals such as bootstrap intervals or Bayesian intervals should be considered.

Child rearing and child outcomes in Japan and the UK

Japan and the UK are compared in relation to various child health outcomes. It is noted that in the rates of child abuse and criminal activity, Japan is in a more favorable position. Rates of behavior problems and suicide rates are very similar in the two countries. Consideration is given to the reasons for the differences. The rates of single parents and divorce are much lower in Japan. The rates of working mothers are about the same, but Japanese women work longer hours. However, it is suggested that more important differences may lie in the greater respect for authority and emphasis on discipline and conformity in Japan. The effects of industrialization on family life and on child development are summarized. It is suggested that the separation of the adolescent age group from the rest of the population has had especially negative results in Western industrialized countries. Various suggestions are made concerning the positive role that pediatricians can play in promoting child development. In particular, pediatricians are encouraged to support and not undermine parents, to involve fathers in management of illness and disability, to press for full implementation of the United Nations Convention on the Rights of the Child, and for ready availability of good substitute child care facilities.

Use of the urine cortisol-to-creatinine ratio for monitoring dogs with pituitary-dependent hyperadrenocorticism during induction treatment with mitotane (o,p'-DDD)

OBJECTIVE

To determine whether the urine cortisol-to-creatinine ratio (UCCR) could replace the ACTH stimulation test in monitoring effectiveness of mitotane induction treatment in dogs with pituitary-dependent hyperadrenocorticism (PDH).

ANIMALS

15 dogs with PDH.

PROCEDURE

All 15 dogs were given an induction dose of mitotane (o,p'-DDD: 35 to 50 mg/kg of body weight/d) for 3 to 14 days. During the induction period, free-catch morning urine samples were collected for determination of UCCR, followed by ACTH stimulation testing, every other day. Treatment response was divided into 3 categories: well-controlled PDH (post-ACTH serum cortisol concentration > or = 28 nmol/L but < or = 138 nmol/L), deficient cortisol secretion (post-ACTH serum cortisol concentration < 28 nmol/L), and excess cortisol secretion (post-ACTH serum cortisol concentration > 138 nmol/L).

RESULTS

The linear relation between UCCR and post-ACTH serum cortisol concentration was significant (P < 0.001); however, the prediction intervals surrounding the line were too broad to be clinically useful. The UCCR overlapped among the 3 categories of treatment response. Nevertheless, dogs with PDH receiving mitotane induction treatment and with UCCR > 79 x 10(-6) were always classified as having excess cortisol secretion.

CONCLUSION AND CLINICAL RELEVANCE

The UCCR failed to predict post-ACTH cortisol concentration during mitotane induction treatment sufficiently close to be a clinically reliable indicator of treatment control. Seemingly, however, UCCR > 79 x 10(-6) obtained from a dog with PDH during mitotane induction would indicate inadequate adrenal cortex destruction and the need for continued mitotane induction; UCCR < or = 79 x 10(-6) would be inconclusive.

WHO and the mental health of children

WHO's work on child mental health began with John Bowlby's classic on the subject, written for WHO in the early 1950s. In the mid-1970s the Division of Mental Health was created, and this led to major advances in establishing a sound epidemiological and scientific basis for child mental health services. Significant contributions were made to the establishment of "biobehavioural" interventions to tackle the major causes of childhood mortality and morbidity throughout the world, and to provide better care for children with mental disorders at primary level.

How should we introduce high-dose chemotherapeutic strategies into the adjuvant management of high-risk breast cancer in Australasia?

BACKGROUND

Development of bone marrow support techniques has altered the standard chemotherapeutic management of haematological malignancies, and these techniques are now being increasingly utilized in solid tumours. In breast cancer, survival benefits have resulted from conventional dose adjuvant chemotherapy, but outcomes remain poor in many women with high-risk disease. Improved response rates with high-dose chemotherapy (HDC) in metastatic disease have led to the investigation of these techniques in adjuvant therapy of high-risk localized disease. In some high-risk patient subgroups survival is extremely poor, with 5-year rates below 30%. Improved adjuvant strategies for patients in these subgroups are therefore urgently required. In Australasia, oncology departments are currently considering accrual of women with high-risk disease into the International Breast Cancer Study Group (IBCSG) 15-95 Trial investigating HDC/stem cell transplantation.

METHODS

The present paper reviews the available data on the efficacies and toxicities of currently available high-dose chemotherapeutic strategies; discussing methodological considerations relevant to their introduction and safe use in the adjuvant setting in Australia and New Zealand.

RESULTS

Although response rates with HDC in metastatic disease are encouraging, the clinical effectiveness of current HDC regimens in adjuvant management has not been established and is limited by significant toxicity.

CONCLUSIONS

The introduction of HDC strategies for high-risk breast cancer in Australia encounters difficulties both in trial design and potential clinical practice.

High iron status in very low birth weight infants is associated with an increased risk of retinopathy of prematurity

To explore the hypothesis that excessive iron loads may increase the formation of free radicals and the development of retinopathy of prematurity in preterm infants, we carried out a prospective observational study of the association between transfusion volume, iron status, and retinopathy.

Climate and aeroallergen levels in asthma: a 12 month prospective study

BACKGROUND

There is evidence to suggest that changes in weather and airborne fungal spore and pollen counts may affect asthma symptoms.

METHODS

The relationship between climate, airborne fungal spore, and pollen counts and peak expiratory flow rate (PEFR) and asthma symptoms was prospectively investigated in a population of mild to moderate asthmatic subjects in Blenheim, New Zealand. Subjects recorded twice daily PEFR measurements and asthma symptom scores for up to one year. Spore and pollen counts were measured two hourly and meteorological data were measured hourly. Individual, within person, multiple linear regression analyses were conducted, adjusting for auto-correlation. A random effects model was assumed for the individual regression co-efficients and weighted estimates of the mean of these coefficients were obtained by the method of maximum likelihood.

RESULTS

One hundred and thirty nine asthmatic patients (60% atopic) aged 17-80 years completed the study. Of the weather variables, only temperature showed a small but consistent association with PEFR. The mean rise in PEFR for an 8.8 degrees C (2 SD) change in temperature was 0.78% (95% CI 0.44% to 1.11%), approximately 3.0 l/min. There was a weak association between days of high basidiospore counts and increased nocturnal wakening and reliever medication use. Pollen counts showed no consistent association with either PEFR or asthma symptoms.

CONCLUSIONS

The results of this study suggest that the effects of weather and aeroallergens on PEFR and asthma symptoms in this population are small, and that other causes need to be sought to account for variations in asthma severity and exacerbations.

Pion radiation for high grade astrocytoma: results of a randomized study

PURPOSE

This study attempted to compare within a randomized study the outcome of pion radiation therapy vs. conventional photon irradiation for the treatment of high-grade astrocytomas.

METHODS AND MATERIALS

Eighty-four patients were randomized to pion therapy (33-34.5 Gy pi), or conventional photon irradiation (60 Gy). Entry criteria included astrocytoma (modified Kernohan high Grade 3 or Grade 4), age 18-70, Karnofsky performance status (KPS) > or = 50, ability to start irradiation within 30 days of surgery, unifocal tumor, and treatment volume < 850 cc. The high-dose volume in both arms was computed tomography enhancement plus a 2-cm margin. The study was designed with the power to detect a twofold difference between arms.

RESULTS

Eighty-one eligible patients were equally balanced for all known prognostic variables. Pion patients started radiation 7 days earlier on average than photon patients, but other treatment-related variables did not differ. There were no significant differences for either early or late radiation toxicity between treatment arms. Actuarial survival analysis shows no differences in terms of time to local recurrence or overall survival where median survival was 10 months in both arms (p = 0.22). The physician-assessed KPS and patient-assessed quality of life (QOL) measurements were generally maintained within 10 percentage points until shortly before tumor recurrence. There was no apparent difference in the serial KPS or QOL scores between treatment arms.

CONCLUSION

In contrast to high linear energy transfer (LET) therapy for central nervous system tumors, such as neutron or neon therapy, the safety of pion therapy, which is of intermediate LET, has been reaffirmed. However, this study has demonstrated no therapeutic gain for pion therapy of glioblastoma.

Pressure-limited ventilation with permissive hypercapnia and minimum PEEP in saline-lavaged rabbits allows progressive improvement in oxygenation, but does not avoid ventilator-induced lung injury

OBJECTIVE

To determine whether pressure-limited intermittent mandatory ventilation with permissive hypercapnia and positive end-expiratory pressure (PEEP) titrated to arterial oxygen tension (PaO2) prevents or reduces acute lung injury, compared to conventional ventilation, in saline-lavaged rabbits.

DESIGN

Prospective randomised trial.

SETTING

University animal laboratory.

SUBJECTS

18 New Zealand White rabbits.

INTERVENTIONS

Following five sequential saline lung lavages, anaesthetised rabbits were randomly allocated in pairs to receive either of two ventilation protocols using intermittent mandatory ventilation. The study group had peak inspiratory pressure limited to 15 cm H2O and arterial partial pressure of carbon dioxide (PaCO2) was allowed to rise. The control group received 12 ml/kg tidal volume with rate adjusted for normocarbia. PEEP and fractional inspired oxygen (FIO2) were adjusted to maintain, PaO2 between 8 and 13.3 kPa (60 and 100 mm Hg) using a predetermined protocol. At 10 h or following death, lung lavage was repeated and lung histology evaluated.

MEASUREMENTS AND MAIN RESULTS

The mean increase in lavage cell counts and protein concentration and hyaline membrane scores were not significantly different between the groups. Oxygenation progressively improved more in the study group (p = 0.01 vs control for PaO2/FIO2 ratio and alveolar-arterial oxygen tension gradient (AaDO2)). PEEP was similar and the mean airway pressure higher in the control group, suggesting that this probably resulted from less ventilator-induced injury in the study group. Four deaths occurred in the control group (three due to pneumothorax and one to hypoxaemia) and none in the study group (p = 0.08).

CONCLUSIONS

This ventilatory protocol may have failed to prevent lung overdistension or it may have provided insufficient PEEP to prevent injury in this model; PEEP greater than the lower inflection point of the pressure-volume curve has been shown to prevent injury almost entirely.

The correlation of elevated levels of an index of lipid peroxidation (MDA-TBA) with adverse outcome in the very low birthweight infant

The objective of this study was to examine the relationship between malondialdehyde-thiobarbituric acid (MDA-TBA) levels, as a measure of lipid peroxidation, in very low birthweight (VLBW) infants and outcome measures. A prospective observational longitudinal study was carried out in two level III neonatal units in the South Island of New Zealand measuring MDA-TBA levels in 61 VLBW infants in 1993. MDA-TBA levels were measured in (i) maternal plasma within 48 h of parturition, (ii) cord plasma, and (iii) infants' plasma at 2, 7, 14 and 28 days of age and correlated with antenatal and postnatal factors. Elevated levels of plasma MDA-TBA at 7 days were associated with adverse respiratory and ophthalmological outcome in the VLBW infants. Elevated MDA-TBA levels were measured at sample times close to the time of death in the infants who died. These results substantiate previously reported preliminary observations and support the hypothesis that oxidative injury, particularly within the first 7 days of life, is associated with the development of the long-term complications of the pre-term infant. MDA-TBA levels appear to be a useful measure to continue to explore the role of free radical mediated disease in the VLBW infant.

Tolerance of nicotinamide and carbogen with radiation therapy for glioblastoma

Nineteen patients with glioblastoma were treated with nicotinamide and carbogen and radiotherapy. Eight patients did not complete the protocol because of hepatic toxicity from phenytoin/nicotinamide drug interactions, persistent nausea or vomiting with nicotinamide, intolerance of the carbogen breathing apparatus, or other reason. In addition, early radiation neurotoxicity appeared increased.

Sigmoidoscopy

The use of a rigid sigmoidoscope, a skill any GP can easily acquire, may save a patient the inconvenience and expense of the more complex procedures of flexible colonoscopy or barium enema. Most colonic pathology occurs within reach of a 25 cm sigmoidoscope. Rigid sigmoidoscopy can be quickly and safely performed in most cases without bowel preparation and in the GP's office.

Psychiatric problems in children with hemiplegia: cross sectional epidemiological survey

OBJECTIVE

To examine the prevalence and predictors of psychiatric problems in children with hemiplegia.

DESIGN

Cross sectional questionnaire survey of an epidemiological sample with individual assessments of a representative subgroup. The questionnaire survey was repeated on school age subjects four years later.

SUBJECTS

428 hemiplegic children age 2 1/2-16 years, of whom 149 (aged 6-10 years) were individually assessed.

MAIN OUTCOME MEASURES

Psychiatric symptom scores and the occurrence of psychiatric disorder.

RESULTS

Psychiatric disorders affected 61% (95% confidence interval 53% to 69%) of subjects as judged by individual assessments and 54% (49% to 59%) and 42% (37% to 47%) as judged from parent and teacher questionnaires, respectively. Few affected children had been in contact with child mental health services. The strongest consistent predictor of psychiatric problems was intelligence quotient (IQ), which was highly correlated with an index of neurological severity; age, sex, and laterality of lesion had little or no predictive power.

CONCLUSION

Though most hemiplegic children have considerable emotional or behavioural difficulties, these psychological complications commonly go unrecognised or untreated. Comprehensive health provision for children with chronic neurodevelopmental disorders such as hemiplegia should be psychologically as well as physically oriented.

Histamine forming capacity (HFC) and its modulation by H3 receptor ligands in a model of bronchial hyper-responsiveness

The histamine forming capacity (HFC) of acutely challenged airways from sensitised guinea pigs was investigated. After exposure to nebulised bovine serum albumin (BSA) or normal saline, animals were sacrificed, the pulmonary HFC determined and concurrent in vitro histamine log concentration response curves were constructed for parenchymal strips and tracheal muscle, the latter was field stimulated to record neurogenic responses. Exposure to BSA increased the HFC above controls for 24 hours (p < 0.001) and log concentration response curves for the parenchymal strips were shifted slightly to the left with an increased maximum response. This change appeared 3 hours after exposure and remained elevated at 24 hours. Similar changes did not occur with the trachea. Pre-treatment with thioperamide augmented (p < 0.02) HFC and this increase was inhibited by alpha-methylhistamine (p < 0.05). A possible relationship may exist between increased responsiveness of lower airways to exogenous histamine and a raised endogenous formation, regulated by the H3 receptor.

Development and characterization of a monoclonal antibody 369.2B specific for the carboxyl-terminus of the beta A4 peptide

The beta-amyloid deposits in Alzheimer's diseased (AD) brain are made up mainly of beta A4 peptides which show both N- and C-terminal heterogeneity. The predominant C-terminal species, identified by peptide sequencing of purified beta-amyloid, end either at position 40 or 42 of the beta A4 peptide. The distribution of these two beta A4 species in postmortem tissue as well as their generation in vitro could not be addressed previously due to the lack of specific antibodies that could differentiate them. This report describes the generation of a highly specific monoclonal antibody, MAb 369.2B which was raised against a synthetic peptide consisting of the C-terminus of the 1-42 beta A4 species. MAb 369.2B does not recognize the shorter beta A4 species 1-40 in solution or in solid phase. Furthermore, both beta A4 1-40 and 1-43 were unable to absorb out the antibody when used immunocytochemically. The regional distribution of MAb 369.2B immunoreactivity in AD and non-AD brain samples were compared to MAb 286.8A, an antibody raised against the N-terminal region of beta A4. Overall, the staining patterns were very similar. In AD cases with extreme vascular involvement, the N-terminal (MAb 286.8A) antibody was more likely to label the vascular basement membrane of affected vessels, and to label them more uniformly. In addition, preliminary quantitative analyses revealed that the C-terminal antibody labeled fewer, larger plaques than the N-terminal antibody. Qualitative analyses revealed that these smaller plaques were typically subregions of the larger plaques. The data corroborate the biochemical findings of N-terminal raggedness in beta A4 plaques. Further studies are required to explain this differential pattern of deposition.

A community-wide promotion of asthma self-management in New Zealand

Asthma affects approximately 9% of young adults in New Zealand, with evidence of an increase in prevalence over recent years. Morbidity and mortality from this condition have caused widespread concern. In response to identified deficiencies in asthma management, initiatives to promote self-management using an asthma action plan were promoted throughout the Canterbury region in 1991 as part of a regional pilot study. A resource kit was prepared and self-management principles were promoted to general practitioners in discussion workshops. A community-wide promotion of the action plan was followed by a process and outcome evaluation. The plan and associated resources were well received by doctors and patients. Seventy-seven percent of doctors responding to a questionnaire had used the plan, and of these, 94% indicated that they would continue to use the plan in the future. Patients who obtained a completed plan experienced a greater reduction in nocturnal waking with asthma and improved self-management skills.

Sexually abused and nonabused mothers' discussions about sex and their children's sexual knowledge

This study investigated the impact of a mother's experience of childhood sexual abuse on her discussion of sex with her child. Two groups of sexually abused and nonabused mothers, drawn from a larger community sample and matched for social class and the sex and age of their index children, were asked about discussion of sexual information within their family. Children were interviewed about their sexual knowledge. Significantly more mothers who reported an incident of sexual abuse during their childhood said that they had detailed discussions with their child about sexual development and contraception than mothers who reported no childhood incidence of abuse. Although there was no difference between the two groups in independent interviewers' ratings of the children's overall sexual knowledge, more children from the abused mothers' group mentioned their parents as a definite source of sexual information, in particular, regarding contraception. There were also differences between the two groups in the children's responses to a set of ambiguous pictures. More children in the abused mothers' group than the nonabused group gave stories related to child abductions and the possibility of sexual abuse in response to two of the pictures. A mothers' willingness to acknowledge childhood sexual abuse is related to more open discussion of sexual information within the family.

Ethical issues in biological psychiatric research with children and adolescents

OBJECTIVE

This article reviews, discusses, and elaborates considerations and recommendations summarized by the biological research working group at the May 1993 NIMH conference on ethical issues in mental health research on children and adolescents.

METHOD

Notes from the conference were summarized and supplemented by a computer search of relevant literature. Drafts were circulated for comment to national and international experts, some of whom joined as coauthors.

RESULTS

Issues addressed include possible overprotection by policy makers and institutional review boards arising out of the recognition of children's special vulnerability without equal recognition of their need for research; the definition of minimal risk, which has often been equated with no risk in the case of children; assessment of the risk-benefit ratio; procedures for minimization of risk, such as improved technology, "piggybacking" onto clinical tests, and age-appropriate preparation; the difficulty of justifying risk for normal controls; age-graded consent; special considerations about neuroimaging; "coercive" inducement, both material and psychological; disposition of unexpected or unwanted knowledge about individuals, including the subject's right not to know and parent's right not to tell; and socioeconomic status and cultural/ethnic equity.

CONCLUSIONS

The working group adopted a position of advocacy for children's right to research access while recognizing that this advocacy must be tempered by thoughtful protections for child and adolescent subjects.

Prevalence of childhood asthma symptoms in an industrial suburb of Christchurch

AIM

In response to community concern about the possible respiratory effects of emissions from a fertiliser plant, a study was carried out to determine whether the prevalence of asthma symptoms in 5-8 yr old children in an industrial suburb of Christchurch (Hornby) was the same as in the rest of Christchurch.

METHODS

A sample of 646 children aged 5-8 years in Hornby was compared with 1183 6-7 year old children randomly selected from schools throughout the Christchurch metropolitan area. The Christchurch sample was part of the International Study of Asthma and Allergies in Childhood (ISAAC) carried out during 1993. ISAAC questionnaires on respiratory symptoms with some additional questions about smoking and pets were answered by the caregivers of the children sampled.

RESULTS

Response rates were 97% in Hornby and 94% in Christchurch. Of the sample, 29% (Hornby) and 27% (Christchurch) had 'wheeze in the last 12 months' while 45% of Hornby and 44% of Christchurch children had 'ever wheezed', 28% had 'ever had asthma'. Significantly more children in Hornby (44%) were exposed to passive smoking compared to Christchurch (29%). Indoor pets were present in 73% and 67% of homes, respectively.

CONCLUSION

There was no evidence of an increase in asthma symptoms reported in children in the industrial area of Hornby.