Sleep problems in pre-school children: a review of the literature

This paper reviews the literature on sleep problems in pre-school children, aiming to raise awareness of the current knowledge in this field. The article begins with a discussion of the prevalence of sleep problems in young children. Disorders of initiating and maintaining sleep are by far the most common type of sleep problem in this age group, and are therefore the focus of this review. The effects of sleep disturbance are examined, focusing on how parents often feel desperate and in need of support outside the family. The causes of sleep problems are considered and the complexity in identifying causal factors is highlighted. The article continues with an exploration of the treatment of sleep problems, suggesting that much of the advice given to parents is contradictory. The literature demonstrates that the use of medication is common, but it appears that this method of treatment is of limited benefit. It seems that behaviour modification or a psychodynamic approach may be much more successful, and the use of self-help manuals/booklets has been shown to be useful by some authors. Finally, preventative strategies are discussed highlighting the need for further research in this area.

Factors influencing the outcome and duration of removable appliance treatment

The study models and records of 150 consecutively completed removable appliance cases were analysed and the influence of various factors assessed on both the change in Peer Assessment Rating (PAR) score produced by treatment and the duration of treatment. For the purpose of analysis the material was divided into two groups; a functional appliance/headgear group (n = 43) and an upper removable appliance group (n = 103). The initial PAR score accounted for 71 per cent of the variation in PAR change in the functional/headgear group when combined with the sex of the patient; females on average showing a further improvement of 3 PAR points over equivalent males. The initial PAR score alone accounted for 68 per cent of the variation in PAR change in the upper removable appliance group. Sixty per cent of the variability in treatment duration could be explained in the functional/headgear group by the initial PAR score and a binary variable indicating whether three or more appliances had been required. Fifty-six per cent of the variability in duration in the upper removable appliance group was explained by the number of appliances used alone. Regression equations for prediction of outcome and duration of removable appliance treatment are given.

Angiocentric invasion by lentigo maligna melanoma

A case of angiocentric invasion by a lentigo maligna melanoma is reported. Pericapillary cuffing and permeative intimal expansion of veins by melanoma without luminal tumour cell emboli, thrombosis, or vascular destruction were associated with a lentigo maligna melanoma on the face of a 93 year old woman. This unusual infiltrative pattern suggests a specific interaction between melanoma cells and perivascular connective tissue elements, and may imply expression by tumour cells of receptors for molecules in the intima of blood vessels and in pericapillary stroma.

HIV prevention in prisons and jails: obstacles and opportunities

High rates of human immunodeficiency virus (HIV) infection among jail and prison inmates suggest that HIV prevention efforts should focus on incarcerated populations. Overcrowding, the high prevalence of injection drug use, and other high-risk behaviors among inmates create a prime opportunity for public health officials to affect the course of the HIV epidemic if they can remedy these problems. Yet, along with the opportunity, there are certain obstacles that correctional institutions present to public health efforts. The various jurisdictions have differing approaches to HIV prevention and control. Whether testing should be mandatory or voluntary, whether housing should be integrated or segregated by HIV serostatus, and whether condoms, bleach, or clean needles should be made available to the prisoners, are questions hotly debated by public health and correctional officials. Even accurate assessment of risk-taking within the institutions leads to controversy, as asking questions could imply acceptance of the very behaviors correctional officials are trying to prevent. Education and risk-reduction counseling are the least controversial and most widely employed modes of prevention, but the effectiveness of current prevention efforts in reducing HIV transmission in this high-risk population is largely undetermined.

A comparison of three salmonella antigen-capture ELISAs and culture for veterinary diagnostic specimens

Three sandwich-ELISAs, two of which are commercially available (Tecra and Locate), and one developed at the Veterinary Sciences Division, Stormont and a 3-step culture protocol, were compared for the detection of salmonella in 1000 animal specimens. Eight hundred and fifty of these were new submissions and the remainder were frozen portions from specimens previously shown to contain salmonellas by culture. The incidence of ELISA false-negative and false-positive results was highest for the Stormont and Locate kits respectively although the differences in sensitivity and specificity between the three ELISAs was not statistically significant. On 16 occasions all ELISA methods indicated the presence of salmonellas when none were isolated by initial culture, eight of these specimens contained salmonellas when reinvestigated by culture.

Influence of counterregulatory hormones, independently of hypoglycaemia, on cognitive function, warning symptoms and glucose kinetics

1. To assess the influence of counterregulatory hormones, independently of neuroglycopaenia, on higher cerebral (cognitive) function, 'hypoglycaemic' warning symptoms and glucose kinetics, 10 healthy subjects participated in two hyperinsulinaemic (2 m-units min-1 kg-1) glucose clamp studies. After 100 min of euglycaemia (plasma glucose level 5 mmol/l), the plasma glucose level was either (a) maintained at 5 mmol/l for 120 min by glucose infusion with concomitant replacement of counterregulatory hormones (continuous infusions of glucagon, adrenaline, noradrenaline, cortisol and growth hormone) to mimic the hormonal milieu normally associated with hypoglycaemia (hormone infusion study) or (b) lowered to 2.8 mmol/l for 120 min (hypoglycaemia study). Assessments were made of cognitive function (P300 auditory evoked responses), symptoms (visual analogue scales) and glucose kinetics (3-[3H]glucose). 2. Hypoglycaemia was associated with an increase in all symptoms (facial flushing, palpitations, tingling, trembling, sweating, hunger, light-headedness and sleepiness, P < 0.01) and all subjects were aware that blood glucose levels had fallen. P300 evoked potential latency increased from 280 +/- 6 to 312 +/- 5 ms (mean +/- SEM, P < 0.01). In contrast, P300 latency and several individual symptoms (hunger, facial flushing, sweating and light-headedness) did not change from baseline during the hormone infusion study (P < 0.05 versus hypoglycaemia). Hepatic glucose production was lower (1.5 +/- 0.4 versus 2.3 +/- 0.3 mg min-1 kg-1, P < 0.05) and peripheral glucose uptake was higher (7.4 +/- 1.0 versus 5.6 +/- 0.6 mg min-1 kg-1, P < 0.01) during infusion of the hormones compared with during hypoglycaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Smoking in diabetic teenagers

The prevalence of smoking amongst a group of 77 diabetic teenagers aged 11-18 years attending two paediatric clinics was determined using a questionnaire and urine cotinine assay. Five individuals were identified as definite smokers with two further individuals being probable smokers, all of whom were aged 15 years or more. This low prevalence (9%) is in contrast to a 48% prevalence in a young adult diabetic clinic. Many diabetic teenagers appear to acquire a regular smoking habit after leaving the paediatric clinic so it is important that health education is targeted at this group.

Otoneurological functioning in panic disorder patients with prominent dizziness

Fifteen panic disorder patients with prominent dizziness underwent audiologic, caloric, and vestibuloocular reflex activity testing and were compared with normal controls. There were no abnormalities detected on audiologic and caloric tests. Compared with normal controls, panickers with dizziness showed a greater discrepancy between eye and head movements on vestibulo-ocular reflex activity in the dark. Panickers with prominent dizziness did not differ from a second control group of panickers with severe heart palpitations on a number of psychological tests. The results did not support the hypothesis that organic dizziness is etiologically important in the causation of panic or agoraphobia, but do suggest that vestibuloocular reflex activity should be further studied in panic disorder.

ECMO in newborn infants: the New South Wales experience

Extracorporeal membrane oxygenation (ECMO) has been used at the Prince of Wales Children's Hospital, Sydney for the treatment of newborn infants with life-threatening respiratory or cardiac failure since August 1989. The main indications are that the disease is reversible, the surviving infant is likely to be normal and there is an 80% likelihood of death without ECMO. Eighteen of 19 newborn infants have survived at least 2 months after ECMO. The 15 infants receiving ECMO (nine with meconium aspiration, six with persisting pulmonary hypertension) who did not have a congenital diaphragmatic hernia were normal survivors. One death occurred at 5 months of age from chronic lung disease. Three of four infants with congenital diaphragmatic hernia were discharged following ECMO and appeared normal at 6, 9 and 18 months of age. These results are similar to results from other centres internationally. It appears that ECMO is a useful therapy for near-term newborn infants with otherwise fatal cardiorespiratory failure.

Diagnostic application of monoclonal antibodies to outer membrane protein for rapid detection of Salmonella

Monoclonal antibodies produced to Salmonella enteritidis outer membrane proteins were screened against 57 Salmonella serovars and several related enterobacteria. Those detecting all Salmonella serovars and none of the related enterobacteria were used in a microtitre plate antigen capture ELISA to screen clinical samples. Sixty-one of 2100 samples yielded salmonellas after incubation for 24 h in selective media by conventional culture. Of these 58 were detected by the ELISA. Sixty-five false positives by ELISA were found to be Enterobacter spp. The results show the potential of this ELISA to eliminate a large proportion of the salmonella-negative cultures at an early stage.

Studies on Australian snake venoms, Part II: The haematological effects of brown snake (Pseudonaja) species in the dog

The haematological effects of Brown Snake (Pseudonaja) species (textilis, affinis, nuchalis) were studied in anaesthetised, mechanically ventilated dogs. Marked thrombocytopenia, depletion of serum fibrinogen and prolonged prothrombin and activated partial thromboplastin time, were recorded at 5 to 10 and 30 to 40 minutes after intravenous envenomation. Fibrin degradation products were not elevated. Because these haematological effects occurred simultaneously with cardiovascular depression (previously reported), we postulate that hypotension sometimes observed in human envenomation may be due to intravascular coagulation with myocardial ischaemia.

Mechanical ventilation of paediatric patients with asthma: short and long term outcome

In the 7 years from 1982 to 1988, 10,639 children with acute asthma were admitted to the Royal Children's Hospital, Melbourne. Of these, 262 children (2%) were treated in the Intensive Care Unit. Twenty-seven required mechanical ventilation on 34 occasions, being 0.3% of hospital asthma admissions. Five patients died, four due to brain death following respiratory arrest prior to intubation. The main complications were (i) barotrauma, which occurred in five patients on seven occasions (20%); (ii) a reversible myopathy which occurred in three patients treated with high dose corticosteroids and muscle relaxants. Follow-up of patients ventilated in intensive care revealed that all but one of the initial survivors was alive 1-5 years later, all patients required subsequent readmission to hospital for treatment of acute asthma and 78% had persistent rather than episodic asthma. Although uncommon, an episode of ventilation has a major impact on the family's understanding and future management of acute asthma.

A survey of methicillin-resistant Staphylococcus aureus affecting patients in England and Wales

For a six-month period between October 1987 and March 1988, 660 isolates of methicillin-resistant Staphylococcus aureus (MRSA) from 570 patients were sent to the Staphylococcus Reference Laboratory at Colindale to supplement the National reporting survey of MRSA in England and Wales. The isolates were characterized by phage typing, antibiotic susceptibility and by selected biochemical tests. Patient details were also surveyed. Fourteen strains affected more than one hospital and were called multi-hospital epidemic strains. One strain, EMRSA-1, accounted for more than 40% of isolates and of patients. Other epidemic strains were defined. Ten additional strains were restricted to single hospitals. Only 25 primary isolates were non-typable but 67 sporadic typable strains occurred. The patients affected were approximately equally either infected or colonized. The sexes were represented equally. Orthopaedic and geriatric wards were over-represented. Epidemic strains were clumping factor positive while some sporadic strains were weak producers. Urea alkalinization and protein A production could supplement phage typing and antibiotic resistance in strain recognition.

Knowledge of HIV infection and AIDS, and attitudes to testing and counselling among general practitioners in Northern Ireland

All 922 general practitioners in Northern Ireland were sent a questionnaire on human immunodeficiency virus (HIV) infection and the acquired immune deficiency syndrome (AIDS). Five hundred and ninety four general practitioners (64.4%) returned the questionnaire. Thirty eight respondents (6.4%) knew of an HIV positive patient in their practice and 93.3% felt they should be informed if one of their patients was found to be HIV positive at a genitourinary medicine clinic, even without the patient's consent. Of the respondents, 76.8% were willing to be involved in the management of AIDS patients in their practice in cooperation with hospital colleagues but only 37.5% felt confident to provide AIDS counselling and advice. Of the 368 general practitioners who did not feel confident to provide AIDS counselling and advice, 41.3% felt that they had insufficient knowledge and 79.6% felt uncertain of their counselling skills. The information gathered on the administration of injections, taking blood samples and disposal of needles indicated that further education for general practitioners is required to ensure safety at work.

HIV testing in patients with end stage renal disease

One hundred and twenty eight British and Irish nephrologists were questioned about their policy for HIV testing of patients with end stage renal failure being considered for renal replacement therapy. A total of 101 (79%) replied. In the case of candidates for dialysis roughly one third of respondents tested only people they considered at risk of infection with HIV and nearly one fifth considered testing unnecessary. In the case of candidates for transplantation routine HIV testing was carried out by 68 of 100 nephrologists; 22 tested only patients "at risk" and 10 did not test. A positive HIV test result was considered by most but not all respondents (63/86) to exclude patients from transplantation. Twenty four of 88 nephrologists considered that HIV positivity should exclude patients from haemodialysis, but only seven of 87 would exclude such patients from peritoneal dialysis. Similar attitudes pertained for patients with end stage renal failure who refused HIV testing. Testing with the patient's knowledge and consent was the policy of two thirds of nephrologists, but a patient's signature was obtained by only 24 of 88. There should be a consensus on practice for HIV testing of patients with end stage renal failure.

Studies on Australian snake venoms. Part 1: The haemodynamic effects of brown snake (Pseudonaja) species in the dog

The haemodynamic effects of Brown Snake (Pseudonaja) species (textilis, nuchalis, affinis) were investigated in anaesthetised, mechanically ventilated dogs. Blood pressure decreased to minimal levels five minutes after intravenous envenomation. Hypotension was accompanied by significant decrements in cardiac output and stroke volume and a rise in peripheral vascular resistance. Heart rate increased transiently during 0.5-2.0 minutes after envenomation but had declined below resting levels five minutes after envenomation. No statistically significant change was recorded in central venous pressure. Depression of myocardial contractility is postulated as the mechanism of venom induced hypotension.

Sexual attitudes and practices of selected groups in Northern Ireland since the emergence of AIDS

One hundred and seventeen heterosexual males and females attending a sexually transmitted disease clinic and 57 homosexual males from a local "gay" club were asked to complete a questionnaire regarding their attitudes and sexual practices since the emergence of AIDS. The results show a trend towards increasing partner change rate among heterosexual males. There has been an increase in the practice of insertive anal intercourse by homosexual men with Northern Ireland contacts but no corresponding increase with contacts outside Northern Ireland. The practice of receptive anal intercourse has remained constant. Significant differences in attitudes between homosexual and heterosexual males were expressed with regard to testing of 'at risk groups' (p less than 0.001), in the uptake of testing (p less than 0.01), and in attitudes to sexual practices if they themselves became HIV positive. There was a low level of anxiety amongst heterosexuals regarding risk of HIV infection in the future. Less than 50% of the heterosexual patients attending this clinic use condoms, though more claim to intend to use them in future.

Antiemetic therapy for chemotherapy-induced vomiting: metoclopramide, benztropine, dexamethasone, and lorazepam regimen compared with chlorpromazine alone

Twenty-six children aged 4 to 15 years who were to receive cancer chemotherapy were enrolled in a double-blind, randomized, crossover trial that compared the antiemetic efficacy of a four-drug regimen (the MBDL regimen: metoclopramide, 8 mg/kg; benztropine, 0.04 mg/kg; dexamethasone, 0.7 mg/kg; lorazepam, 0.1 mg/kg), given over 24 hours, with the efficacy of chlorpromazine, 3.3 mg/kg, given in four doses over 24 hours. The MBDL regimen was more effective than chlorpromazine in both objective and subjective measures of antiemetic control. Of 26 children, 23 (89%) had less vomiting on the MBDL regimen, and 20 (77%) of 26 patients or parents preferred this regimen (p less than 0.01). The MBDL regimen reduced the number of vomiting episodes by a mean of 4.0 (p less than 0.01) and reduced the duration of vomiting by a mean of 3.7 hours (p less than 0.01). A moderate level of sedation was documented at some stage in the 24-hour period of observation in 27% on the MBDL regimen and in 35% receiving chlorpromazine. Dystonia was seen in 1 (4%) of 26 children. We conclude that the MBDL regimen is safe in children and more effective than chlorpromazine.

Mesolimbic dopamine receptor increases two weeks following hippocampal kindling

Kindled seizures developed in rats following repeated electrical stimulation of the left CA1 region of the hippocampus. Two weeks after the final kindled seizure, the densities of dopamine (DA) D2 receptors were assayed in the left and right amygdaloid area, nucleus accumbens, and nucleus caudatus. A significant increase (107%) in the density of DA D2-receptors in the ipsilateral nucleus accumbens occurred. This finding may help to define the long-term neurochemical consequences of kindling.

Reliability of Boder's classification of spelling errors: naive raters

Boder-type screening tests were constructed from basic school readers. Three naive raters classified spelling errors of 104 monolingual and bilingual reading-disabled children according to Boder's patterns of dysphonetic, dyseidetic, and mixed strategies. The reliabilities were .53 for one rater and .77 for three raters.

Potential of indium-111 to measure inflammatory arthritis

Since an objective noninvasive method for measuring inflammation in arthritis is lacking, radioimaging experiments were conducted with 111indium-chloride (111InCl3) in the collagen model. A computer imaging index, reflecting uptake in the feet and ankles, was significantly greater in 16 rats immunized with collagen than in 6 nonimmunized rats (mean +/- SEM 1.18 +/- 0.04 vs 0.39 +/- 0.02, for the 2 groups, respectively, p less than 0.001). Additional analyses provided evidence that the 111InCl3 technique can be used to measure objectively progression of the arthritic response of rats of immunization with collagen, and pilot comparisons with conventional bone scintigraphy in 2 patients with rheumatoid arthritis suggested that the method is applicable to human arthritic disease.

Distribution and mechanism of uptake of 111InCl3 in a tumor model for lymph node metastases

The localization of 111In activity in the tumor and draining lymph nodes of the H-4-II-E ACI rat hepatoma was investigated following the injection of 111In-chloride. In this tumor model, the tumors metastasize to the regional lymph nodes in male rats only. The following experiments were performed: (a) biodistribution of 111In; (b) correlation of 111In uptake with [3H]thymidine; (c) gamma camera imaging; (d) autoradiography; (e) iron competition and (f) binding of 131I-transferrin to H-4-II-E cells. Tumor-to-muscle ratios of 111In in males were 4.9:1 in the primary tumor and 9.1:1 in the metastatic lymph nodes 24 h post injection. In the lymph node metastases in the males, a significant correlation between 111In uptake and [3H]thymidine was observed (r = 0.737) suggesting that 111In uptake in the metastases is related to cellular proliferation. No such correlation was observed in either primary tumors (both male and female) or in the draining lymph nodes of the females. Metastatic lymph nodes in males could be detected in gamma camera images while draining nodes in females could not be delineated. Injection of ferric citrate prior to 111In administration resulted in a significant reduction of 111In uptake in the liver, spleen and tumor and increased the amount of activity recovered from the kidney. Measurements of the binding of 131I-labeled rat transferrin to H-4-II-E cells in vitro suggest that these cells display transferrin receptors.