Child, parent, and therapist (dis)agreement on target problems in outpatient therapy: the therapist's dilemma and its implications

A minimal requirement for success in child psychotherapy is arguably that child, parent, and therapist agree about which problems to address. How often is this the case? Following clinic intake, the authors asked 315 children, parents, and therapists, separately, to identify target problems. More than 3/4 of child-parent-therapist triads began treatment without consensus on a single problem; nearly half failed to agree on even I broad problem domain (e.g., aggression vs. anxiety/depression). Therapists agreed more with parents than children for most child problems, but for family and environmental problems the reverse was true. Findings highlight the therapist's dilemma in identifying treatment foci when clients disagree and may help explain the poor effects of clinic-based therapy reported in previous research.

Treatment-related acute renal failure in the elderly: a hospital-based prospective study

BACKGROUND

Elderly individuals need a host of diagnostic procedures and therapeutic interventions to take care of ailments. This prospective study was carried out to determine the magnitude of treatment-related acute renal failure (ARF) in the elderly in a hospital setting, to know about pathogenetic factors and to study the factors that could predict an adverse outcome.

METHODS

All elderly patients (>60 years) admitted over a 12-month period were screened prospectively throughout their hospital stay for the development of ARF.

RESULTS

Of 31860 patients admitted, 4176 (13%) were elderly. Of these 59 (1.4%) developed ARF in the hospital. Nephrotoxic drugs contributed towards development of ARF in 39 (66%), sepsis and hypoperfusion in 27 (45.7%) each, contrast medium in 10 (16.9%) and postoperative ARF occurred in 15 (25.4%) patients. These pathogenetic factors were responsible for ARF in different combinations. Amongst these combination of pathogenetic factors, radiocontrast administration (partial chi(2) 28.1, P<0.0001), surgery (partial chi(2) 14.89, P=0.001), and drugs (partial chi(2) 6. 22, P=0.0126) predicted ARF on their own. Nine patients (15.23%) needed dialytic support. Of 59 patients, 15 (25.4%) died, of those who survived, 38 (86.3%) recovered renal function completely and six (13.6%) partially. Mortality in the elderly with ARF was significantly higher than in those without ARF (25.4 vs 12.5%; chi(2) 8.3, P=0.03). Sepsis (odds ratio 43), oliguria (odds ratio 64), and hypotension (odds ratio 15) were independent predictors of poor patient outcome on logistic regression analysis.

CONCLUSION

Incidence of treatment-related ARF in the elderly was 1.4%, with more than one pathogenetic factor playing a role in the development of ARF in the majority. Sepsis, hypotension, and oliguria were the independent predictors of poor patient outcome.

An evaluation of radical prostatectomy at Veterans Affairs Medical Centers: time trends and geographic variation in utilization and outcomes

OBJECTIVE

To examine temporal trends and geographic variation in utilization of radical prostatectomy (RP) as well as 30-day mortality and complication rates.

DESIGN

Administrative data-base study of radical prostatectomy (RP) using the Department of Veterans Affairs Patient Treatment File and Outpatient Clinic File between 1986 to 1996. Logistic regression was used to estimate temporal and geographic effects on the use of RP.

SETTING

All Departments of Veterans Affairs Medical Centers (VAMC) in the contiguous United States.

PATIENTS

Men aged 45 to 84 years who underwent RP at a VAMC (n = 13,398).

MAIN OUTCOME MEASURES

Number and utilization of RP, rate of 30-day mortality, major cardiopulmonary or vascular complications, and colorectal injuries requiring surgical repair within 30 days of RP.

RESULTS

From 1986 to 1996, the annual number of RP at VAMCs (range, 695-1,545 RP) more than doubled, and the rate of RP at VAMCs per male VA user increased by 40% (range, 48/100,000-66/100,000). After controlling for age and year, the utilization of RP in West North Central, Mountain, West South Central, and Pacific census divisions was 70%, 14%, 10%, and 8% higher, respectively, whereas the utilization of RP in New England, East North Central, and Mid-Atlantic divisions was 38%, 31%, and 25% lower, respectively, than the rest of the nation (P<0.001). Geographic variation in utilization decreased during the period between 1986 and 1996, but a twofold difference in RP utilization in 1996 remained between high- and low-utilization divisions. Major cardiopulmonary complications, vascular complications, and colorectal injuries occurred in 1.7%, 0.2%, and 1.8% of men, respectively. Thirty-day mortality was 0.73%, declined from 1986 to 1996, and was associated with a history of diabetes and congestive heart failure.

CONCLUSION

Utilization of RP at VAMCs increased over time and varied across geographic areas. Thirty-day mortality was less than 1% and decreased with time. Differences in utilization may be caused by uncertainty regarding the effectiveness of early detection and treatment of prostate cancer.

Seasonal influences on admissions in schizophrenia and affective disorder in Ireland

Although the seasonal patterns of admissions of affective disorder have been extensively studied, less attention has been given to the seasonal admission patterns of schizophrenia. The traditional method of aggregating the data over a study period, rather than analysing by year of admission may obscure potentially relevant fluctuations in the seasonal pattern. We examined the year-to-year variation in the admission patterns of schizophrenia and affective disorder in Ireland. Using the National Psychiatric Inpatient Reporting System (NPIRS), individuals admitted with an ICD-9/10 diagnosis of a first episode of schizophrenia or affective disorder during the 6-year period 1989-1994 were identified. Seasonal variations in their admission patterns were examined statistically and graphically. There was a significant seasonal variation in the monthly admission patterns of both schizophrenia and affective disorder. This pattern was more marked for individuals with affective disorder. However, the seasonal pattern was not constant from year to year, particularly for schizophrenia.

The use of alcohol home delivery services by male problem drinkers: a preliminary report

Alcohol home delivery services (AHDS) provide convenient and confidential access to alcohol, yet little is known about their use. The purpose of this report is to present preliminary data describing the use of AHDS by problem drinkers. We surveyed 174 males regarding social and demographic characteristics, alcohol use history, and use of AHDS. Use of AHDS was most common among problem drinkers. When statistically controlling for the effects of demographic and social characteristics, regular drinkers without a history of alcohol problems were significantly less likely to have had alcohol delivered than problem drinkers, p = .0036. Contrary to expectation, medically ill alcoholics with advanced and disabling medical complications of heavy drinking were not more likely than other problem drinkers to have alcohol delivered. Living in an urban area and not having a vehicle available were associated with the use of AHDS. The public health and safety considerations of alcohol availability via home delivery are discussed.

Angiotensin converting enzyme gene deletion allele is independently and strongly associated with coronary atherosclerosis and myocardial infarction

OBJECTIVE

To investigate the association of the three angiotensin converting enzyme (ACE) genotypes, DD, ID, and II, with the occurrence or absence of coronary atherosclerosis and with myocardial infarction and hypertension.

DESIGN

Cohort analysis study.

SETTING

North-Italy reference centre.

SUBJECTS

388 white Italian patients (281 males; mean age 60.7 (SD 12.5) years) with proven coronary atherosclerosis (n = 255) or with angiographically normal coronary arteries (n = 133). A further group of 290 healthy blood donors was tested for allele frequency comparison.

INTERVENTIONS

ACE/ID polymorphism was analysed with polymerase chain reaction on DNA from white blood cells.

MAIN OUTCOME MEASURES

Coronary atherosclerosis, myocardial infarction, hypertension.

RESULTS

The D and I allele frequencies were respectively 0.63 and 0.37 in the overall healthy blood donor group and 0.66 and 0.34 in the overall study group. In the latter, univariate analysis showed (1) that coronary atherosclerosis (255 patients) was associated with the deletion allele, with an odds ratio (OR) of 5.78 for DD/II, P < 0.001, and 2.39 for ID/II, P = 0.006; and (2) that myocardial infarction (154 patients) was associated with the DD genotype (OR DD/II = 2.56, P = 0.007), but not with the ID genotype (OR DD/II = 1.96, P = 0.056). Finally, hypertension proved to be unrelated with the ACE genotype. The distribution between the three genotypes of known risk factors for coronary artery disease was similar. Logistic regression modelling, performed to test the association of the selected risk factors simultaneously with coronary atherosclerosis and myocardial infarction, showed that the deletion allele (whether DD or ID) was the strongest risk factor for atherosclerosis, and that the D allele was significantly associated with the risk of infarction (although to a lesser extent than with coronary atherosclerosis).

CONCLUSION

ACE deletion polymorphism is strongly and independently associated with coronary atherosclerosis and, to a lesser extent, with myocardial infarction. As such, the results are analogous to what has already been reported in French white, Japanese, and Welsh coronary patients.

Establishment size and risk of occupational injury

For many years, the annual survey of occupational injuries and illnesses by the Federal Bureau of Labor Statistics (BLS) has consistently reported, without explanation, that injury rates in the smaller establishments (< 50 employees) are substantially lower than those for midsize establishments (100-499 employees). Also during those years, a remarkable increase has been reported in the injury rate in large companies, following the imposition of stiff fines for failure to keep required injury records. The rate patterns are identical for Michigan and the country in general. We investigated possible causes for lower injury rates in small establishments since such rates are inconsistent with reports of higher fatality rates in small establishments in the mining, construction, manufacturing, and transportation industries and higher, or at least comparable, injury rates for small establishments in the mining industry. They are also inconsistent with increased turnover and decreased availability of occupational safety services in small companies. Moreover, injury severity, as measured by missed worktime, is greater for workers in small establishments. We investigated the possibility that interactions of workforce or injury characteristics with establishment size could explain the rate differences. We also reviewed the available literature to see whether differences in labor turnover rates could explain the BLS findings. Graphical and statistical analyses of the 1988 CPS Annual Demographic File, a sample of employed persons in the U.S. workforce, failed to identify any associations between workforce characteristics and enterprise size that would explain the lower rates. Similarly, graphical and statistical analyses of all Michigan workers incurring a compensable injury in 1986 failed to indicate any associations between injury characteristics and establishment size that would explain the lower rates. The potential role of labor turnover on the injury rate was analyzed from data in the literature on turnover rate by establishment size and risk of injury by time on the job. None of these analyses explains the lower injury rates reported for small establishments. This leaves underreporting of injuries from small establishments as a substantial possibility. If small establishments were subject to the same injury incidence rates as midsize establishments, then the 1986 survey for Michigan may have missed as many as 54,000 injuries (and far more nationally). We suggest that BLS undertake methodological studies to validate the completeness of reporting from small establishments.

Graphical models for panel studies, illustrated on data from the Framingham Heart Study

Recursive graphical models allow description of the simultaneous development of several (discrete) characteristics such as are recorded in a panel study. Irreversible events (death, irreversible disease occurrence) between exams are naturally included. This paper reviews these models and gives a detailed discussion of an example consisting of 49-50 year old males from the Framingham Heart study. The program DIGRAM is used throughout and the present paper may also serve as an introduction to this software.

Staging of carcinoma of the pancreas and ampulla of Vater. Tumor (T), lymph node (N), and distant metastasis (M) as prognostic factors

Between 1984 and 1987, 472 Norwegian patients with histologically or cytologically verified carcinoma of the pancreas (N = 442) and ampulla of Vater (N = 30) were accrued and TNM staged according to UICC. The influence of the T, N, and M categories on long-term survival was evaluated. The T1a and T1b tumors of stage I pancreatic carcinoma had a comparable survival (p = 0.68-0.95). A higher T category (T1-T3) predicted a more dismal prognosis (p = 0.000). The T1 and T2 carcinomas of the ampulla of Vater had a comparable favorable prognosis, and the T3 and T4 tumors had a comparable unfavorable prognosis. The N1 vs N0 (p = 0.000-0.01) and M1 vs M0 categories (p = 0.00-0.003) predicted a more dismal prognosis for both pancreatic and ampullary carcinoma. By logistic regression analyses, pancreatic tumor extension into peripancreatic fat or nerves and invasion of ampullary carcinomas into duodenal wall, unfavorably influenced the N1 category (p = 0.000-0.04) and tumor diameter influenced the M1 category (p = 0.002-0.04) both for pancreatic and ampullary carcinoma. The T, N, and M categories all independently influenced survival of pancreatic carcinoma (p = 0.000-0.003). Only the N category (p = 0.01) influenced the prognosis of ampullary carcinomas.

Interdependence of different genetic EEG patterns in siblings of epileptic patients

The present study is based on the data of a more extensive investigation of the genetics of spike-wave epilepsies of childhood with minor seizures (Doose and Baier 1987). It evaluated EEG findings in 271 siblings of patients by means of log-linear methods. The risk of siblings to manifest spikes and waves during rest or hyperventilation is distinctly increased if they are positive for 4-7 Hz rhythms, and to a lesser degree, if they are photosensitive. Moreover, siblings of female patients seem to be at a higher risk of manifest spikes and waves than siblings of males. 4-7 Hz rhythms of the EEG background activity and photosensitivity are mutually independent symptoms of an increased liability to manifest spikes and waves. These findings are discussed in the context of a 'multifactorial' background of spikes and waves.

Children's understandings of the attributes of life

Previous investigations of children's understandings of the life concept have focused on their classifications of the life status of familiar objects. In this study, we attempted to examine more directly the processes by which children infer life status by examining their reasoning about unfamiliar objects. In Experiment 1, 4- to 11-year-olds and adults were asked to name attributes of living things to establish which attributes they associated most closely with life. Children age 7 and younger most often named attributes true only of animals but not of plants; older children more often named attributes true of both animals and plants. However, movement was the single attribute cited most frequently by children of all ages tested. In Experiment 2, 4- to 11-year-olds and adults were presented information about attributes of imaginary objects on a distant planet and were asked to infer if those objects were alive. Again, young children relied relatively heavily on qualities true only of animals but not of plants, whereas older children relied more on attributes true of both plants and animals. Also as before, movement was viewed as indicative of life at all ages tested. In Experiment 3, we examined the hypothesis that children discriminate among different types of motion and that the types of motion they associate with life are in fact typical of living things. Children ranging from age 5 through 11 were found to discriminate among different types of motion and to infer that objects were alive only when they showed the types of motion typical of living beings. The results of Experiment 3 allowed interpretation of seemingly conflicting results that have arisen in previous studies, as well as in Experiments 1 and 2 of the present study.

Factors associated with progression of coronary artery disease in patients with normal or minimally narrowed coronary arteries

This study was performed to identify the subset of patients with normal or with minimal (49% or less) stenosis of the coronary vessels who may be prone to progressive coronary artery disease (CAD). Data were collected from 51 patients (19 men, 32 women, mean age 48 years) with normal coronary arteries (20 patients) or with minimal narrowing (31 patients) on a first angiogram, who underwent repeat catheterization 4 to 120 months later (mean 52) because of persistent chest pain. Three classic lifestyle-related risk factors (systemic hypertension, cigarette smoking status and hypercholesterolemia) were noted; the number of diseased segments on the first angiogram was counted according to a 15-segment coding system. Progression of CAD required the consensus of 3 observers on a 30% or greater decrease in luminal diameter. Progression was recorded in 16 of 31 patients with minimal CAD and in 3 of 20 patients with normal coronary arteries (p less than 0.01). By multivariate logistic regression, progression was predicted by (1) number of diseased segments (p = 0.001), (2) age (p less than 0.01), (3) smoking status (p less than 0.05) and (4) initial cholesterol level (p less than 0.05). Using the probability computed by the logistic model, we could separate the 51 patients in groups with low (0 of 18), medium (9 of 23) and high (10 of 10) risk of progression. Thus, patients with normal or minimally narrowed coronary arteries at angiography form a heterogeneous population including both normal or borderline subjects and patients with CAD at its early stage. The latter condition was associated with presence of risk factors and to the angiographic extent of the disease.

Multivariate logit analysis of concordance ratios for quantitative traits in twin studies

The application of multiway contingency table analysis to the multivariate analysis of concordance ratios in twin studies is developed. The approach is illustrated by data on smoking and alcohol use in Finland and Sweden. This approach can enable the assessment of the effect of other variables on the concordance ratio and thus allow estimates of genetic effects on the trait under study. Hypotheses on relationships between genetic effects and other variables can be tested. After hypothesis testing, model fitting of the best hypothesis can be carried out.

Conditions relevant to the occurrence of acid-fast bacilli in sphagnum vegetation

Biotopes with intact sphagnum vegetation were studied in Naustdal, West Norway: the health district with the former highest leprosy incidence rates in Norway. Concentration of acid-fast bacilli and concentration of non-cultivable acid-fast bacilli found in the vegetation fluid were compared with a series of variables related to the local environment and to the samples of vegetation. In bivariate analyses high concentrations were found in biotopes with orientation toward South, with a high coverage of vascular plants and with presence of Ericaceae. High concentrations were also found where dry weight of a vegetation was high, where pH in the fluid was low and where dry weight of the fluid was high. In a multivariate analysis, log-linear model, based on concentration of acid-fast bacilli as the dependent variable and orientation, pH, dry weight of vegetation and dry weight of fluid as the independent variables, all two-factor effects including the dependent variable were retained in the model. Furthermore, orientation versus dry weight of vegetation and dry weight of fluid versus dry weight of vegetation were retained.

Risk of pelvic inflammatory disease among users of intrauterine devices, irrespective of previous pregnancy

The use of an intrauterine device (IUD) in 690 patients hospitalized for acute salpingitis (pelvic inflammatory disease) was compared with IUD use in a sexually active age-matched control group. Two hundred and twenty (31.9%) of the patients and 114 (16.5%) of the controls were wearing IUDs. Thus, the relative risk of developing acute salpingitis was 2 among IUD users. No significant difference was found in IUD use in the two groups between nulligravid women and women who had been pregnant. It was shown furthermore that the use of the oral contraceptives decreases the risk of salpingitis by two thirds. A lower frequency of gonorrhea among PID patients who were IUD users was revealed also.

Risk of pelvic inflammatory disease among intrauterine-device users irrespective of previous pregnancy

The use of intrauterine devices (IUD) in 690 patients admitted to hospital for pelvic inflammatory disease (PID or acute salpingitis) was compared with the use in a sexually active age-matched control group. 220 (31.9%) of the patients and 114 (16.5%) of the controls were using an IUD. Thus, the risk of PID was raised twofold by IUD use. No significant difference was found between the women who had never been pregnant and those who had in the two groups. Neither was the risk of PID found to vary with age.