Statutory health assessments for looked-after children: what do they achieve?

OBJECTIVE

To examine the outcomes of statutory health assessment of children looked after by an English City Council.

DESIGN

Retrospective longitudinal documentary analysis.

SETTING AND PARTICIPANTS

Health records of all children looked after by Southampton City Council who had attended at least two statutory health assessments within a designated paediatric service from 1996 to 1999.

MAIN VARIABLES STUDIED

Demographic characteristics of the children; physical and mental health problems identified at assessment and extent to which health recommendations were implemented.

RESULTS

Twenty-seven boys and 22 girls aged 6 months-15 years were identified who had attended at least two assessments. One-hundred and four physical and mental health needs were identified at care entry requiring further assessment or intervention. More health problems were identified for girls than boys. At care entry 15/49 of the children were not fully immunized. At review, on average 14 months later, recommendations had only been implemented in just over half of children.

CONCLUSIONS

In common with previous studies this work confirms that the statutory health assessment identifies health need and health neglect that may otherwise go unrecognized. Whereas children's needs and problems were diverse, many continued to suffer health neglect in the system of public care designed to help them. In order to be effective, statutory health assessments must be a health promoting rather than disease screening exercise delivered by professionals skilled to address diverse health needs. Crucially, the heath assessment can only succeed as a tool for health advocacy if complementary to and integrated with local authority care and review.

Using local authority data for action on health inequalities: the Caerphilly Health and Social Needs Study

BACKGROUND

Primary care organisations in the United Kingdom have been given new and challenging population health responsibilities to improve health and address health inequality in local communities through partnership working with local authorities. This requires robust health and social needs assessment data for effective local planning.

AIM

To assess the use and value of local authority data shared through partnership working between Caerphilly Local Health Group and Caerphilly County Borough Council.

DESIGN OF STUDY

Cross-sectional analysis of aggregate electoral division data.

SETTING

Caephilly County Borough, south-east Wales.

METHOD

Local authority datasets identified were categorised into one of six domains: income, unemployment, housing, health, education, and social services. Data were presented at electoral division level as rates in thematic maps and correlations between the variables within and between each domain were explored using Spearman's rank correlation coefficient, with particular focus on children in families. Local planning documents were scrutinised to ascertain the use and value of the data.

RESULTS

A broad range of data described a comprehensive picture of health and social inequalities within the borough. Multiple deprivation tended to cluster in electoral divisions, particularly for data relating to children, painting an overwhelming picture of inequality in life chances. The data were used in a wide range of local partnership planning initiatives, including the Health Improvement Programme, Children's Services Plan, and a successful Healthy Living Centre bid.

CONCLUSION

Local authority data can help primary care organisations in a population approach to needs assessment for use in local partnership planning targeted at reducing health inequalities.

A comparison of different biogeographical classifications of Europe, Great Britain and Spain

Various biogeographical and bioclimatic classifications of a number of regions, countries and continents have been created to meet different objectives. A policy maker might ask the question 'why is there no single accepted classification and how do the different classifications compare with one another?' In order to answer these two questions three classifications created by different methods for Great Britain and two for Spain are compared using the Kappa statistic. All of the classifications were created from data on cellular grids with a set window size. Further non-statistical comparisons are made with other classifications. The biogeographic classifications studied in this paper produced three different types of zone: those that were always identified whatever the method; those that were broadly similar but where the boundaries differed; and those that were unique to a particular classification. These different types of zone are likely to exist for any comparison between classifications of a particular region. The extent of the geographic window from which data were obtained had a major effect on the classification of grid cells at the edges of the window. For example, the few grid cells in the south of England, with characteristics of continental Europe, are not detected if data from Great Britain alone are used for the classification. We conclude that the data window should always be larger than the area for which the classification is being made. The objective Kappa statistic, although useful, was not capable of discerning similarities and dissimilarities that appear obvious to the subjective human eye. Although the details of the classifications differed there were broad similarities between the classifications and these differences reflect important divisions along major environmental axes that have been inferred by earlier biogeographers. As the divisions are real there is a sound basis for their use in future land use or environmental policy.

A simple modified membrane filtration medium for the enumeration of aerobic spore-bearing bacilli in water

Aerobic spore-bearing bacilli have been proposed as a surrogate indicator for the removal of Cryptosporidium by drinking water treatment processes. Pasteurisation of samples followed by culture on non-selective media is the method of choice. Using white membranes for filtration of water samples makes colony counting difficult. Vital dyes such as neutral red or trypan blue can help when added to the growth medium but these dyes tend to colour the membrane and reduce the contrast between the colonies and the background. The incorporation of bromothymol blue at a concentration of 0.005% (w/v) into nutrient agar facilitated colony counting without inhibiting colony formation compared with unsupplemented nutrient agar. Statistical analysis of the data (ANOVA) confirms this observation. The modified technique was found to be satisfactory with spore suspensions of Bacillus globigii and B. cereus as well as with samples of surface water, settled water and drinking water.

Development and validation of the Glasgow Epilepsy Outcome Scale (GEOS): a new instrument for measuring concerns about epilepsy in people with mental retardation

PURPOSE

To develop a measure for use with adults with epilepsy and mental retardation, capable of assessing both clinical and care concerns and of quantifying treatment outcomes.

METHODS

Extensive validational and other psychometric evaluation was undertaken, comprising initial scale development work with 48 carers and 46 health practitioners, followed by formal field testing on a sample of 186 patients, using 384 respondents (160 clinicians, 141 staff, 83 family). Recognised qualitative methods were applied to identify central themes, and psychometric procedures generated data on validity, reliability, and component structure.

RESULTS

A total of 1,007 items of concern was generated, which was reduced systematically to a representative set of 90 items. The GEOS-90 comprises four subscales: concerns about "seizures," "treatment," "caring," and "social impact," each explaining approximately 70% of variance. Subscales and factor scales had strong internal consistency (alpha > or = 0.82). Stepwise linear regression was applied to derive a short-form version with similar structure. Thirty-five items were retained (GEOS-35; alpha > or = 0.89). Both scales discriminated moderately on clinical variables (number of seizure types, mono- vs. polytherapy, seizure frequency; all values of p < 0.05) and demonstrated concurrent validity with interview ratings from the ELDQOL (p < 0.05).

CONCLUSIONS

The GEOS scales appear valid and reliable for use with clinical populations of people with mental retardation.

Residual neurologic deficits 30 years after occupational exposure to elemental mercury

A battery of tests of peripheral and central nervous system function was administered to 205 former workers of a large heavy industrial plant, 104 of whom were previously exposed to inorganic mercury. The mean age of those examined was 71 years. Exposed subjects had participated in a urine-mercury exposure monitoring program during the time of operation of a process that required the use of mercury and its subsequent clean-up. Mercury exposure had been high (mean peak urine mercury concentration was >600 microg/l) and had ended 30 years or more prior to the investigation. Peripheral nerve function outcomes that were statistically significantly associated with cumulative mercury exposure after controlling for covariates included classification as having peripheral neuropathy, peroneal motor nerve conduction velocity, ulnar motor nerve conduction velocity, and peroneal motor nerve F-wave latency. Quantitative assessment of resting tremor was nearly significantly associated with cumulative mercury exposure (p=0.07). Among tests of central nervous system function, results of the Handeye Coordination test were significantly associated with cumulative mercury exposure after controlling for covariates. Cumulative mercury exposure was not observed to be associated with a quantitative measure of dementia or with a number of cognitive neurobehavioral test outcomes. The statistically significant associations with mercury exposure were observed in spite of greater mortality among the exposed group than the unexposed group. These results suggest that substantial occupational mercury exposure can have long-term adverse effects on the peripheral nervous system detectable decades after cessation of exposure. Such long-term adverse effects were not observed for a measure of dementia or other measures of cognitive function.

External radiation exposure and mortality in a cohort of uranium processing workers

In a study of 2,514 White male workers employed between 1942 and 1966 at a US uranium processing plant, mortality was compared with overall US mortality, and the relation between external ionizing radiation and cancer was evaluated. Through 1993, 1,013 deaths occurred. The mean cumulative dose was 47.8 mSv. The standardized mortality ratio (SMR) was 0.90 for all causes of death and 1.05 for all cancers. Many cancer sites had elevated SMRs. Among nonmalignant outcomes, the SMR for chronic nephritis was 1.88 (six deaths observed). An excess relative risk estimate of 10.5 per Sv (10 cases) was observed for kidney cancer; this may have resulted from chance, internal radiation, or chemical exposures not considered.

A social cognitive-based model for condom use among college students

BACKGROUND

Social cognitive theory has been used extensively to explain health behaviors. Although the influence of one construct in this model-self-efficacy-has been well established, the role of other social cognitive constructs has not received as much attention in human immunodeficiency virus (HIV) prevention research. More complete understanding of how social cognitive constructs operate together to explain condom use behaviors would be useful in developing HIV and sexually transmitted disease (STD) prevention programs for college students.

OBJECTIVE

The primary aim of this study was to test a social cognitive-based model of condom use behaviors among college students.

METHODS

Data were collected from a sample of college students attending six different colleges and universities. Participants were 18 to 25 years of age, single, and sexually active. For the sample of 1,380 participants, the mean age was 20.6 years (SD = 1.76). Most participants reported having had vaginal intercourse (95.8%) and oral sex (86.5%); 16% reported anal sex.

FINDINGS

Self-efficacy was related directly to condom use behaviors and indirectly through its effect on outcome expectancies. As predicted, self-efficacy was related to anxiety, but anxiety was not related to condom use. Substance use during sexual encounters was related to outcome expectancies but not to condom use as predicted.

CONCLUSIONS

Overall, the findings lend support to a condom use model based on social cognitive theory and provide implications for HIV interventions. Interventions that focus on self-efficacy are more likely to reduce anxiety related to condom use, increase positive perceptions about condoms, and increase the likelihood of adopting condom use behaviors.

Coverage by the news media of the benefits and risks of medications

BACKGROUND

The news media are an important source of information about new medical treatments, but there is concern that some coverage may be inaccurate and overly enthusiastic.

METHODS

We studied coverage by U.S. news media of the benefits and risks of three medications that are used to prevent major diseases. The medications were pravastatin, a cholesterol-lowering drug for the prevention of cardiovascular disease; alendronate, a bisphosphonate for the treatment and prevention of osteoporosis; and aspirin, which is used for the prevention of cardiovascular disease. We analyzed a systematic probability sample of 180 newspaper articles (60 for each drug) and 27 television reports that appeared between 1994 and 1998.

RESULTS

Of the 207 stories, 83 (40 percent) did not report benefits quantitatively. Of the 124 that did, 103 (83 percent) reported relative benefits only, 3 (2 percent) absolute benefits only, and 18 (15 percent) both absolute and relative benefits. Of the 207 stories, 98 (47 percent) mentioned potential harm to patients, and only 63 (30 percent) mentioned costs. Of the 170 stories citing an expert or a scientific study, 85 (50 percent) cited at least one expert or study with a financial tie to a manufacturer of the drug that had been disclosed in the scientific literature. These ties were disclosed in only 33 (39 percent) of the 85 stories.

CONCLUSIONS

News-media stories about medications may include inadequate or incomplete information about the benefits, risks, and costs of the drugs as well as the financial ties between study groups or experts and pharmaceutical manufacturers.

The impact of a picture archiving and communication system (PACS) upon an intensive care unit

OBJECTIVE

The aim of the study was to assess the effect of the introduction of PACS (Picture Archiving and Communication System) upon image availability in an Intensive Care Unit (ICU) and the consequent impact upon the behaviour of the ICU physicians, in terms of the initiation of image-based clinical actions.

DESIGN

A before and after study was used to compare the speed of image availability prior to, and following, the implementation of a hospital-wide PACS.

SETTING

The research was part of an economic evaluation of PACS at Hammersmith Hospital, West London.

PATIENTS AND PARTICIPANTS

All ICU patients who were X-rayed during two pre-PACS and one post-PACS data collection periods were included within the study.

MEASUREMENTS

The times of: the X-ray request; acquisition; availability on ICU; and of any image-based clinical action taken by the ICU physician were recorded by radiographers and ICU physicians.

RESULTS

PACS significantly reduced the time between request and image availability on ICU for routine X-rays but did not have any measurable impact upon the time clinical actions were initiated by ICU physicians. The data on non-routine images were statistically inconclusive.

CONCLUSIONS

This study shows that PACS significantly improves the speed of delivery of routine images to the ICU, but it appears that the instigation of image-based clinical actions is determined by other organisational factors in ICU, such as ward rounds, rather than the availability of the image for viewing. Further work is required on non-routine X-rays to clarify the impact of PACS on physician behaviour in clinically urgent situations.

A hospital-wide picture archiving and communication system (PACS): the views of users and providers of the radiology service at Hammersmith Hospital

OBJECTIVE

To obtain users' views of the new picture archiving and communication system (PACS) from clinical and radiological staff at Hammersmith Hospital, UK.

METHODS

Semi-structured interviews were used to ascertain the views of staff, following an interview schedule which covered aspects of: (1) their use of PACS, (2) facilities available, (3) the perceived quality of images, (4) reporting, (5) image availability, (6) image accessibility, (7) training, and (8) ease of use of PACS.

RESULTS

Interviews were carried out with 34 key users and providers of the radiological service at Hammersmith Hospital. Overall, staff were very satisfied with PACS particularly in terms of image availability. All staff said that they preferred PACS to the previous, conventional radiology service.

CONCLUSIONS

The key implications of issues raised by staff were: the impact of 'down-time' and the importance of an efficient back-up system, the requirement for sufficient short-term storage to prevent images being off-line during clinical situations, the usefulness of the folder system for management of the images, the need to access images for teaching purposes, the advantage of having a default display protocol to facilitate radiological reporting, and the requirement for flexible, yet effective, training to ensure that the system is utilised to its full potential by users.

Evaluation of a hospital picture archiving and communication system

OBJECTIVES

To establish the net costs to the hospital and the broad range of benefits associated with a hospital-wide picture archiving and communication system (PACS) that comprised digital acquisition, storage and transmission of radiological images via a hospital-wide network to 150 workstations.

METHODS

'Before and after' comparisons and time series analyses at Hammersmith Hospital (London, UK), and comparison with five other British hospitals where PACS was not being installed. The cost analysis considered implementation costs and changes in key elements of hospital running costs, including the impact of changes in the length of inpatient stays. A range of benefit measures were investigated, including image availability, avoidance of repeat imaging, avoidance of exposure to radiation, patient turn-round speed, time from examination to image availability in intensive care, avoidance of diagnostic 'errors' by casualty doctors, the additional diagnostic value of PACS-based images and clinician satisfaction.

RESULTS

The annual equivalent capital cost of the PACS was 1.7 million Pounds (annual equivalent replacement cost: 0.8 million Pound). Overall, the PACS substantially increased running costs. No convincing evidence of a PACS-induced change in length of inpatient stay was found. PACS was associated with some improvements in the performance of the radiology department: improved image availability (97.7% versus 86.9%), lower repeat imaging rate (7.3% versus 9.9%) and 20% lower total radiation doses for examinations of the lateral lumbar spine. No improvements were identified in the quality of the radiology reporting service. Benefits outside radiology included shorter time from examination to image availability for routine uses in intensive care (19 versus 37 minutes), and a lower rate of diagnostic 'errors' in casualty (0.65% versus 1.51%). High levels of satisfaction with PACS were found amongst both providers and clinical users.

CONCLUSIONS

PACS was almost universally preferred by users and brought many operational and clinical benefits. However, these advantages came at a significant capital and net running cost.

Implementation of a multidisciplinary disease management program for heart failure patients

Institutions across the country are considering the feasibility of a disease management program for heart failure (HF) patients. Published reports suggest that such programs can save money and improve outcomes. However, the design of a disease management program can be challenging. This paper describes the structure and function of a successful disease management program for heart failure patients. The program is supported by a multidisciplinary team of nurses, pharmacists, dietitians, social workers, and physicians who approach the problem from a self care perspective. Program components include standardized educational materials, reinforcement of educational contacts, monthly support groups, and a quarterly newsletter. Existing staff built the program with few additional resources and staff. The program, which costs only approximately $330/patient for a 6 month intervention, has decreased hospital readmissions (29%) and days in the hospital (43%) significantly. (c)1999 by CHF, Inc.

Hydrolysis of menhaden oil by a Candida cylindracea lipase immobilized in a hollow-fiber reactor

A lipase from Candida cylindracea immobilized by adsorption on microporous polypropylene fibers was used to selectively hydrolyze the saturated and monounsaturated fatty acid residues of menhaden oil at 40 degrees C and pH 7.0. At a space time of 3.5 h, the shell and tube reactor containing these hollow fibers gives a fractional release of each of the saturated and monounsaturated fatty acid residues (i.e., C14, C16, C16:1, C18:1) of ca. 88% of the corresponding possible asymptotic value. The corresponding coproduct glycerides retained over 90% of the initial residues of both eicosapentaenoic (EPA; C20:5) and docosahexaenoic (DHA; C22:6) acids. The half-life of the immobilized lipase was 170 h when the reactor was operated at the indicated (optimum) conditions. Rate expressions associated with a generic ping-pong bi-bi mechanism were used to fit the experimental data for the lipase catalyzed reaction. Both uni- and multiresponse nonlinear regression methods were employed to determine the kinetic parameters associated with these rate expressions. The best statistical fit of the uniresponse data was obtained for a rate expression, which is formally equivalent to a general Michaelis-Menten mechanism. After reparameterization, this rate expression reduced to a pseudo-first-order model. For the multiresponse analysis, a model that employed a normal distribution of the ratio of Vmax/Km with respect to the chain length of the fatty acid residues provided the best statistical fit of the experimental data.

Commitment to care: managed care and child incarceration

Downsizing and managed care in the 1990s followed the psychiatric hospital scandals and closures of the 1980s. Many families are now unable to provide care for their troubled children. Childhood emotional or behavioral disorders have rapidly spread beyond the confines of the home into a community that has adopted a "zero tolerance" for crime. Intolerance for childhood criminal behavior has resulted in an explosion of children's prisons where, in the name of rehabilitation, many are finally receiving psychological help. This article discusses the decreased treatment of childhood psychiatric disorders and the increased admissions to children's prison facilities.