Certolizumab pegol for the treatment of patients with moderate-to-severe chronic plaque psoriasis: pooled analysis of week 16 data from three randomized controlled trials

BACKGROUND

Certolizumab pegol, an Fc-free, PEGylated, anti-tumour necrosis factor (TNF) biologic, has demonstrated favourable results in three ongoing, phase 3, randomized, double-blinded, placebo-controlled trials in adults with psoriasis.

OBJECTIVE

Data were pooled from the ongoing trials to investigate efficacy in selected subgroups and add precision to estimates of treatment effects during the initial 16 weeks of treatment.

METHODS

In each trial, patients ≥18 years with moderate-to-severe chronic plaque psoriasis for ≥6 months were randomized to receive certolizumab 400 mg, certolizumab 200 mg or placebo every 2 weeks for 16 weeks. Coprimary endpoints for the pooled analysis were responder rates at Week 16, defined as ≥75% reduction in psoriasis area and severity index (PASI 75) and physician global assessment (PGA) of 0/1 ('clear'/'almost clear' with ≥2-category improvement). Safety was assessed by treatment-emergent adverse events.

RESULTS

A total of 850 patients treated with certolizumab 400 mg (N = 342), certolizumab 200 mg (N = 351) or placebo (N = 157) were included in the pooled analysis. At Week 16, PASI 75 and PGA 0/1 responder rates were 80.1% and 63.7% in the certolizumab 400 mg group, 74.5% and 54.6% in the certolizumab 200 mg group, and 7.5% and 2.8% in the placebo group (P < 0.0001 for each dose versus placebo). In patients with and without prior biologic therapy, both doses of certolizumab resulted in substantially higher responder rates versus placebo. The incidence of adverse events was generally similar between the 400 mg and placebo groups, and somewhat lower in the 200 mg group versus placebo. No new safety signals were identified.

CONCLUSION

Certolizumab pegol 400 mg or 200 mg every 2 weeks for 16 weeks was associated with statistically significant and clinically meaningful improvements in signs and symptoms of psoriasis in patients with and without prior biologic therapy, and a safety profile consistent with the anti-TNF class in psoriasis.

Testicular atrophy following paediatric primary orchidopexy: A prospective study

BACKGROUND

With the Nordic consensus statement advocating orchidopexy at an earlier age, the present study sought to investigate the outcomes of primary paediatric orchidopexy at a tertiary UK centre.

OBJECTIVE

To prospectively assess testicular atrophy following primary orchidopexy for undescended testes in a paediatric population. Secondary outcomes were complication rates and whether outcomes were dependent on grade of operating surgeon.

STUDY DESIGN

Prospective data regarding age at operation, classification of the undescended testis, length of follow-up, and subjective comparison of intraoperative and postoperative testicular volumes compared with the contralateral testis were collected. Testicular atrophy was defined as >50% loss of testicular volume or a postoperative testicular volume <25% of the volume of the contralateral testis. Patients were excluded for incomplete data and follow-up <6 months.

RESULTS

Data for 234 patients were analysed. Testicular atrophy occurred in 2.6% of cases. There was no reported testicular re-ascent. All secondary acquired cases underwent a previous ipsilateral hernia repair. There was no significant difference in outcomes comparing the grade of surgeon (consultant n = 8, trainee/staff-grade surgeon n = 7-8). There was a trend towards postoperative catch-up growth in approximately one fifth of cases.

DISCUSSION

Previous studies have reported a testicular atrophy rate of 5%. The present study reported a similar rate of 2.6%. In agreement with a previous publication, it was also found that testicular atrophy was not dependent on the grade of operating surgeon. The mechanism for testicular catch-up growth is not well understood. Animal studies have supported the hypothesis that increased temperature has a detrimental effect on testicular volume. However, follow-up in the present cohort was short (median 6.9 months), making interpretation of this finding difficult. It is acknowledged that clinical palpation alone to determine testicular volume potentially introduces intra-observer and inter-observer error. However, prospective studies using ultrasound to determine testicular volumes following orchidopexy have reported catch-up growth.

CONCLUSION

This study represented one of the larger collections of prospective assessments of outcomes following primary orchidopexy. It was acknowledged that subjectively assessing testicular volume is not ideal; however, the data correlated with similar studies.

An unlikely cause of severe malnutrition in a 3-year-old girl with previous gastroschisis

A 3-year-old girl with previous gastroschisis associated with jejunal and colonic atresia presented with severe oedema, abdominal pain and diarrhoea. Clinically she was malnourished. Serum albumin and concentrations of micronutrients were low. A barium meal examination showed jejunal dilation. A stricture was suspected and the patient was taken to theatre where an 8 cm length of bowel was resected including a jejunal stricture at the point of previous atresia repair. Inside the proximal dilated jejunum was a large trichobezoar (hairball), thought to be acting as a ball valve inside the bowel. This girl made a rapid recovery after surgery. Her nutritional state improved, symptoms resolved and serum biochemistry normalised. She remains well at follow-up with normal blood results, normal albumin and no diarrhoea.

An audit of transfers for neonatal surgical care in England in 2007

OBJECTIVE

To audit the access to specialist services for infants requiring transfer for surgical care in the neonatal networks in England in 2007.

METHODS

Data on neonates transferred for surgical care from January to December 2007 were obtained from the National Neonatal Audit Programme database. Information on origin and destination of transfer was used to assess what proportion of infants required transfer to another network or, in the six network centres without a surgical service, to a more distant surgical centre than appropriate.

RESULTS

Information was available from 18 of the 24 neonatal networks and identified 484 infants transferred for surgery for whom complete data were available. Ninety-one infants (18.8%) were transferred out of network or to a more distant centre than appropriate. This compares with 3.6% for all network patients and far exceeds the maximum figure of 5% recommended by the National Audit Office. Only one network was able to use a single surgical centre for transfers, and the median number of surgical units accessed in the year was 3 (range 1-8).

CONCLUSIONS

Neonates requiring surgical care in England often need transfer beyond the local network. The reasons for this need further investigation by a prospective audit of access to neonatal surgical care.

Helping foster parents cope with separation, loss, and grief

Major changes in planning for children in foster care have resulted in significant changes in the roles of and expectations for foster parents, accompanied by even less attention to the issues of foster families' grief and loss. This article focuses on (1) the many ways foster parents encounter loss and grief on a continuous basis; (2) factors that affect the intensity of the loss and the healthy expression and resolution of grief; (3) problems that can result when the grief of foster parents is not adequately addressed; and (4) ways in which professionals can be helpful to these caregivers around loss and grief.

Toward an interpersonal life-stress model of depression: the developmental context of stress generation

The validity of a developmentally based life-stress model of depression was evaluated in 88 clinic-referred youngsters. The model focused on (a) the role of child-environment transactions, (b) the specificity of stress-psychopathology relations, and (c) the consideration of both episodic and chronic stress. Semistructured diagnostic and life-stress interviews were administered to youngsters and their parents. As predicted, in the total sample child depression was associated with interpersonal episodic and chronic stress, whereas externalizing disorder was associated with noninterpersonal episodic and chronic stress. However, the pattern of results differed somewhat in boys and girls. Youngsters with comorbid depression and externalizing disorder tended to experience the highest stress levels. Support was obtained for a stress-generation model of depression, wherein children precipitate stressful events and circumstances. In fact, stress that was in part dependent on children's contribution distinguished best among diagnostic groups, whereas independent stress had little discriminative power. Results suggest that life-stress research may benefit from the application of transactional models of developmental psychopathology, which consider how children participate in the construction of stressful environments.

A pilot randomised controlled trial of medical versus nurse clerking for minor surgery

BACKGROUND

Nurse led clerking is currently practiced in a growing number of UK centres, but there is a paucity of evidence to underpin the safety of this innovation.

AIM

To assess the safety of nurse led clerking in paediatric day case and minor surgery.

METHODS

Children aged 3 months to 15 years were randomly assigned to clerking by either a nurse or a senior house officer (SHO) (resident). All children were then independently reassessed by a specialist registrar anaesthetist to provide a "gold standard" against which practitioner performance could be judged.

RESULTS

In 60 children studied, nurses identified a significantly greater proportion of the detectable abnormalities present in the sample (p = 0.16). This difference is attributable to nurses' greater accuracy in history taking (p = 0.04); no conclusions regarding the comparability of nurses' and SHOs' skills in physical examination can be derived from the current study.

CONCLUSION

Evidence attests to the likelihood of nursing having superior skills in history taking to SHOs. Exploration of nursing safety in undertaking physical examination, however, requires the conduct of a large scale equivalence study. Only then can conclusions be drawn as to whether nurse led physical assessment offers children a standard of care equivalent to that which they currently receive from SHOs.

Incidence of RET mutations in patients with Hirschsprung's disease

BACKGROUND

RET mutations have been reported variously to affect 7% to 41% of Hirschsprung's disease (HSCR) patients depending on familial or sporadic occurrence of the disease, length of aganglionosis and possible association with other disease phenotypes. The authors report a study of the incidence of RET mutations in unselected HSCR patients from two regional centers and correlate their genotypes and phenotypes.

METHODS

The records of HSCR patients treated in 2 regional centers with a combined population of 5 million were reviewed, and blood samples were obtained from 57 patients. During the same period, 39 patients with similar demographic data refused or provided insufficient blood for study. DNA was extracted, and the 21 exons of the RET protooncogene were screened for mutations using denaturing gradient gel electrophoresis (DGGE).

RESULTS

Of 57 patients, 48 were sporadic, and 9 were familial. Lengths of aganglionosis were total colonic, 4; long, 11; short, 39; ultrashort, 1; unclassified, 2. Associated anomalies were present in 20. Causative mutations were identified in 4 (7%): missense or "silent" in 3 (exons 5, 11, 13) and deletion in 1. The silent mutation of exon 11 recently has been shown to have effects on correct RET mRNA splicing. One mutation occurred in total colonic aganglionosis (25%), 1 in long segment dysganglionosis (9%), and 2 in short segment aganglionosis (5%). Surprisingly, all these mutations occurred in sporadic cases (10%). Five patients (9%) had rare polymorphic alleles at exon 14 (n = 1) and exon 18 (n = 4). Fifty patients (88%) showed common polymorphic alleles (sequence variants) in 1 or more exons (> 4, n = 5).

CONCLUSIONS

RET mutation as a primary cause for Hirschsprung's disease in the general surgical population is less frequent than previously thought. This observation is compatible with the hypothesis that HSCR could be a polygenic disease caused by additive subclinical effects of more than one gene, including RET.

Experiences, concerns, and service needs of families adopting children with prenatal substance exposure: summary and recommendations

Parents who adopted children from out-of-home care with prenatal substance exposure were interviewed four months after the child's placement in the home, and again after the first year regarding their experience with adoption and their concerns about their child's development, attachment, and behavior; aspects of parenting and the adoption process; effects of prenatal substance exposure; and availability and helpfulness of resources. Adoptive parents found parenting children with prenatal substance exposure to be both more rewarding and more difficult than they had imagined.

Depression and Axis II symptomatology in an adolescent community sample: concurrent and longitudinal associations

The relationship between personality pathology and depression has been the focus of increasing attention, but few investigators have examined this issue prospectively or in adolescent community samples. The present study used both self report and interviewer assessments of personality disorder symptomatology and depression in a sample of 155 late adolescent women followed over three years. Personality pathology cluster and total scores demonstrated moderate to fairly high degrees of stability, indicating endurance of these traits in late adolescence. As predicted, Axis II symptoms were associated with concurrent depressive symptomatology. Overall, self-reported personality disorder symptoms, as well as those specifically in Clusters A and B, predicted interviewer-rated depression over two years beyond the contribution of initial depression, indicating that subclinical Axis II symptoms are a risk factor for subsequent depressive symptomatology.

The context of depression in clinic-referred youth: neglected areas in treatment

OBJECTIVE

To review the empirical, methodological, and conceptual limitations of psychotherapy and pharmacotherapy for childhood and adolescent depression and to present descriptive data on key characteristics of a depressed sample to illustrate gaps in treatment.

METHOD

Interview-based assessment of psychiatric features and psychosocial functioning, family psychopathology and marital adjustment, and child and parent stressful life events was performed in a sample of 43 depressed youngsters seeking outpatient treatment.

RESULTS

The empirical and conceptual review indicated that treatments based on downward extensions of adult procedures are limited in number and success. Also, the treatments generally neglect the following characteristics revealed in the descriptive data: depressed youngsters have high rates of recurrent depression and comorbid conditions, impaired academic and social functioning, exposure to high rates of parental psychopathology, parental assortative mating, severe marital dysfunction, and high rates of severe stressors.

CONCLUSIONS

Treatments need to be informed by and address the actual characteristics of depressed youngsters and their environments, which are highly dysfunctional.

Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood

This study examined 2 models of the relationship between personality disorder symptomatology and depression, incorporating life stress as an intervening variable. In a community sample of late adolescent women, symptoms of Cluster B disorders predicted interpersonal chronic stress and self-generated episodic stress over 2 years, controlling for initial depression. Cluster A symptoms also predicted subsequent chronic interpersonal stress, over initial depression. Cluster C pathology did not predict subsequent stress. Personality disorder symptomatology was also associated with partner-reported relationship dissatisfaction. Support was found for a mediation model whereby women with higher levels of initial personality disturbance in Clusters A and B generated excessive amounts of episodic stress and interpersonal chronic stress in the next 2 years, which, in turn, increased vulnerability for depressive symptoms. A moderation model, whereby the presence of greater personality disorder symptoms would increase the likelihood of depression in response to stress, was not supported.

Nursing physical assessment skills: implications for UK practice

The physical assessment skills of inspection, palpation, percussion and auscultation currently have only minimal recognition in UK nursing practice. Authors attest to perceived benefits in terms of continuity of care, holistic care delivery, rapidity of emergency intervention and reduction in junior doctors' hours and workload. However, the use of such skills by nurses has been subject to little in the way of formal outcome-based evaluation, and there is a clear need for such research to be carried out within the UK. Important guidelines exist within the literature to underpin educational programmes in physical assessment; these are reviewed and their implications for UK practice are considered. It is concluded that while generation of a UK evidence base is required, there is a persuasive argument to underpin continued development of physical assessment skills within UK nursing practice.

Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood

This study examined 2 models of the relationship between personality disorder symptomatology and depression, incorporating life stress as an intervening variable. In a community sample of late adolescent women, symptoms of Cluster B disorders predicted interpersonal chronic stress and self-generated episodic stress over 2 years, controlling for initial depression. Cluster A symptoms also predicted subsequent chronic interpersonal stress, over initial depression. Cluster C pathology did not predict subsequent stress. Personality disorder symptomatology was also associated with partner-reported relationship dissatisfaction. Support was found for a mediation model whereby women with higher levels of initial personality disturbance in Clusters A and B generated excessive amounts of episodic stress and interpersonal chronic stress in the next 2 years, which, in turn, increased vulnerability for depressive symptoms. A moderation model, whereby the presence of greater personality disorder symptoms would increase the likelihood of depression in response to stress, was not supported.

Characterization for imperfect polarizers under imperfect conditions

The principles for measuring the extinction ratio and transmittance of a polarizer are formulated by use of the principal Mueller matrix, which includes both polarization and depolarization. The extinction ratio is about half of the depolarization, and the contrast is the inverse of the extinction ratio. Errors in the extinction ratio caused by partially polarized incident light and the misalignment of polarizers can be corrected by the devised zone average method and the null method. Used with a laser source, the null method can measure contrasts for very good polarizers. Correct algorithms are established to deduce the depolarization for three comparable polarizers calibrated mutually. These methods are tested with wire-grid polarizers used in the 3-5-microm wavelength region with a laser source and also a lamp source. The contrasts obtained from both methods agree.

Why does attachment style change?

Adult attachment research has proceeded on the assumption that attachment style is relatively stable and affects future functioning. However, researchers have become interested in attachment instability and predictors of attachment style change. In this article, 2 conceptualizations of attachment style change were examined: Attachment style change is a reaction to current circumstances, and attachment style change is an individual difference in susceptibility to change that is associated with stable vulnerability factors. A total of 155 women were assessed after high school graduation, and 6 months and 2 years later. Results primarily supported the conceptualization of attachment style change as an individual difference. Specifically, some women may be prone to attachment fluctuations because of adverse earlier experiences, and women who show attachment fluctuations are similar to women with stably insecure attachments.

Predictors of the generation of episodic stress: a longitudinal study of late adolescent women

The effects of depression and Axis I comorbidity on subsequent self-generated life stress were examined in a longitudinal sample of 134 late adolescent women. The results indicated that specific forms of psychopathology constitute a risk factor for future self-generated episodic stress, even when controlling for prior chronic stress. Comorbid depression had a particularly salient effect in the prediction of stress related to interpersonal conflicts. The effects of family psychopathology and sociotropy were mediated through participant psychiatric status, whereas autonomy made an independent contribution to the prediction of episodic stress. These results support C. Hammen's (1991b) stress generation model in a community sample, demonstrating how individuals with depression play a role in the creation of stress, and also refine prior work by showing that only the comorbid form of depression is associated with subsequent conflict-related stress.

Predictors of the generation of episodic stress: a longitudinal study of late adolescent women

The effects of depression and Axis I comorbidity on subsequent self-generated life stress were examined in a longitudinal sample of 134 late adolescent women. The results indicated that specific forms of psychopathology constitute a risk factor for future self-generated episodic stress, even when controlling for prior chronic stress. Comorbid depression had a particularly salient effect in the prediction of stress related to interpersonal conflicts. The effects of family psychopathology and sociotropy were mediated through participant psychiatric status, whereas autonomy made an independent contribution to the prediction of episodic stress. These results support C. Hammen's (1991b) stress generation model in a community sample, demonstrating how individuals with depression play a role in the creation of stress, and also refine prior work by showing that only the comorbid form of depression is associated with subsequent conflict-related stress.

A cognitive-interpersonal approach to depressive symptoms in preadolescent children

Cognitive and interpersonal aspects of depressive symptoms were investigated in a community sample of children. Eighty-one 8- to 12-year-olds completed scales assessing cognitive representations of social relationships and symptoms of depression and anxiety. Teachers provided ratings of peer rejection. Children with elevated levels of depressive symptoms displayed increased negativity in their beliefs about self, family, and peers, as well as distinct patterns of interpersonal information processing. Anxiety symptoms did not make a unique contribution beyond depression to negative representations of family and peers; in contrast, symptom-specific profiles of self-representations were found. Structural equation analysis supported a model linking negative interpersonal representations, peer rejection, and depressive symptoms. The findings suggest that future studies may benefit from approaches that incorporate both cognitive and interpersonal variables as predictors of child depression.

The relationship between attachment cognitions and psychological adjustment in late adolescent women

This longitudinal study of 137 female high school seniors investigated the relationship of attachment cognitions, current psychological functioning, and psychological functioning 12 months later. Attachment cognitions, assessed with the Revised Adult Attachment Scale and the Inventory of Parent and Peer Attachment, were significantly associated with current symptomatology. The Revised Adult Attachment Scale, in interaction with initial symptomatology, predicted depression, substance abuse, eating disorders, and personality disorders 12 months later. The Inventory of Parent and Peer Attachment parent subscales predicted eating disorder and personality disorder symptomatology, whereas the peer subscales predicted substance abuse, eating disorder, and personality disorder symptomatology.

Poor interpersonal problem solving as a mechanism of stress generation in depression among adolescent women

The authors examined C. Hammen's (1991) model of stress generation in depression and the role of interpersonal problem-solving strategies (IPS) in the stress generation process in a longitudinal sample of 140 young women who entered the study at ages 17-18. Structural equation modeling was used to test a model in which IPS and subsequent interpersonal stress mediated the relationship between initial and later depressive symptoms. Results supported the main prediction of the stress generation model: Interpersonal stress mediated the relationship between initial and later depressive symptoms. In addition, IPS predicted interpersonal stress. However, no association was found between depressive symptoms and IPS. An alternative model in which IPS moderated the relationship between stress and depressive symptoms was tested; it was not supported.

Cognitive representations of self, family, and peers in school-age children: links with social competence and sociometric status

Attachment and social-cognitive theories of interpersonal relations have underscored the integral role that internalized cognitive representations may play as mediators of the link between family and peer relationships. 3 predictions consistent with this conceptualization received support in the present study of 161 7-12-year-old school children. In Part 1 of the study, significant connections were found among different components of cognitive representations, including social perceptions, interpersonal expectancies, and schematic organization and processing of social information. Moreover, generalization was found among children's representations across 3 interpersonal domains--that is, family, peer, and self. In Part 2, negative representations of self and others were found to be associated with increased social impairment, including dysfunctional social behavior and less positive status in the peer group. Implications of the findings for theories of interpersonal competence and interventions with socially impaired children are discussed.

Interpersonal attachment cognitions and prediction of symptomatic responses to interpersonal stress

The authors tested a cognitive-interpersonal hypothesis of depression by examining the role of interpersonal cognitions in the prediction of depression associated with interpersonal stressors. A measure of adult attachment assessed interpersonal cognitions about ability to be close to others and to depend on others and anxiety about rejection and abandonment. Participants were women who had recently graduated from high school; they were followed for 1 year with extensive interview evaluation of life events, depression, and other symptomatology. Generally, cognitions, interpersonal events, and their interactions contributed to the prediction of interview-assessed depressive symptoms, but the effects were not specific to depression and predicted general symptomatology measured by diagnostic interviews as well, and results also varied by attachment subscale. Results were discussed in terms of a developmental psychopathology approach to disorders in young women.

Gastroschisis and reduced fetal heart-rate variability

Most liveborn babies with gastroschisis do well after surgical repair, although about one-eighth of affected cases die late in utero. Our practice is to use weekly computerised cardiotocograph (CTG) analysis after week 34 of gestation in cases of gastroschisis. In a look-back at the records in 18 such singleton pregnancies, CTG showed 7 to be highly abnormal or preterminal. All but 1 of these 7 had a normal fetal heart rate. In all 7 cases, delivery was expedited. Only 1 infant had neurological sequelae, and in all the abdominal defect was successfully repaired. Monitoring of these high-risk pregnancies with serial computerised CTG may be helpful in timing delivery.

Diaphragmatic herniae and translocations involving 8q22 in two patients

Two girls with congenital diaphragmatic herniae are reported. Both were discovered to have a balanced reciprocal translocation involving 8q22.3. In one girl the translocation was de novo, in the other it was maternally inherited. Uniparental disomy was excluded in both. 8q22.3 may be the location of a gene affecting development of the diaphragm.

Interpersonal functioning and depressive symptoms in childhood: addressing the issues of specificity and comorbidity

Research has supported linkages between depression and social impairment in youngsters, but has often focused on depressive symptoms in isolation. We collected data on depressive, anxiety, and externalizing symptoms in 161 school children. Information about interpersonal competence was gathered from several sources, including children, teachers, and behavioral observations. Depressive symptoms were found to be related to difficulties in multiple areas of competence, including maladaptive social problem-solving styles, conflict-negotiation and affect-regulation deficits, and peer rejection. Comparisons of the relative contributions made by depressive and anxiety symptoms to the prediction of functioning yielded some evidence for a specific relation between depressive symptoms and impairment. Children with cooccurring internalizing and externalizing symptoms generally suffered from the most social dysfunction. If replicated in clinical samples, findings such as these may help to guide intervention efforts with depressed children.

Macular capillary hemodynamic changes associated with Raynaud's phenomenon

BACKGROUND

Raynaud's phenomenon is an episodic, reversible spasm of the digital arterioles. Previous studies have suggested that Raynaud's phenomenon may be associated with alterations in the ocular circulation. The authors used the blue field entoptic simulation technique to study macular retinal capillary hemodynamics in patients with Raynaud's phenomenon.

METHODS

Forty-two volunteers participated in the study: 18 with a connective tissue disease and secondary Raynaud's phenomenon, 8 with a connective tissue disease and no Raynaud's phenomenon, and 16 healthy volunteers. The mean of three blue field entoptic density and velocity measurements was determined before as well as during and 10 minutes after the immersion of one hand in ice water.

RESULTS

Patients with severe Raynaud's phenomenon demonstrated a statistically significant 30% decrease in retinal capillary flow during immersion of a hand in ice water (P less than 0.05), which remained 17% reduced (P less than 0.05) for at least 10 minutes after removal. The decrease in capillary flow was not observed in control individuals or in individuals with connective tissue disease who demonstrated minimal or no Raynaud's phenomenon.

CONCLUSION

The prolonged reduction in retinal capillary flow observed in subjects with Raynaud's phenomenon is probably caused by retinal arteriolar vasoconstriction and is similar to concurrent arteriolar vasoconstriction reported in other systemic vascular beds. In the retina, the recurrent ischemic episodes may result in dysfunction or injury.

Paediatrics: developing family information leaflets

The authors offer advice on how to prepare information leaflets for the families of children admitted to paediatric units, and describe the successful implementation of such a scheme at the University Hospital, Southampton. The development of family information leaflets comprises an important part of setting quality standards.

Maternal communication: predictors of outcome at follow-up in a sample of children at high and low risk for depression

Separate lines of investigation have shown the increased risk of dysfunction for children of depressed women and impaired interaction between depressed mothers and their children. The link between the two was examined in 57 children at high and low risk for depression. Children of unipolar depressed, bipolar depressed, chronically medically ill, and normal mothers were evaluated at a 6-month follow-up. Hierarchical regression analyses suggested a relation between maternal interaction behavior on two dimensions, task focus and affective quality, and children's subsequent depression and school behavior; academic performance was related only to affective quality of interaction. Chronic stress was predictive of more negative, critical maternal behavior, whereas depressed mood was associated with less task involvement. Maternal interactions are viewed as a marker of a complex, mutual process involving interpersonal relationships in an adverse environmental context.

Timing of mother and child depression in a longitudinal study of children at risk

Temporal associations of diagnoses in mothers and children were examined in a 3-year longitudinal study of unipolar, bipolar, and comparison women and their 8- to 16-year-old offspring. There was a significant temporal association between mother and child diagnoses, especially in unipolar families, and most children who experienced a major depressive episode did so in close proximity to maternal depression. Regression analyses indicated that children's own stressful life events, maternal disorder, and the interaction of the two significantly predicted children's changes in depression. Children exposed to high stress but with nonsymptomatic mothers were significantly less depressed subsequent to stressors than those who also had symptomatic mothers. The results are discussed in terms of the reciprocal, interpersonal context of depression.

Timing of mother and child depression in a longitudinal study of children at risk

Temporal associations of diagnoses in mothers and children were examined in a 3-year longitudinal study of unipolar, bipolar, and comparison women and their 8- to 16-year-old offspring. There was a significant temporal association between mother and child diagnoses, especially in unipolar families, and most children who experienced a major depressive episode did so in close proximity to maternal depression. Regression analyses indicated that children's own stressful life events, maternal disorder, and the interaction of the two significantly predicted children's changes in depression. Children exposed to high stress but with nonsymptomatic mothers were significantly less depressed subsequent to stressors than those who also had symptomatic mothers. The results are discussed in terms of the reciprocal, interpersonal context of depression.

Maternal communication: Predictors of outcome at follow-up in a sample of children at high and low risk for depression

Separate lines of investigation have shown the increased risk of dysfunction for children of depressed women and impaired interaction between depressed mothers and their children. The link between the two was examined in 57 children at high and low risk for depression. Children of unipolar depressed, bipolar depressed, chronically medically ill, and normal mothers were evaluated at a 6-month follow-up. Hierarchical regression analyses suggested a relation between maternal interaction behavior on two dimensions, task focus and affective quality, and children's subsequent depression and school behavior; academic performance was related only to affective quality of interaction. Chronic stress was predictive of more negative, critical maternal behavior, whereas depressed mood was associated with less task involvement. Maternal interactions are viewed as a marker of a complex, mutual process involving interpersonal relationships in an adverse environmental context.

Longitudinal study of diagnoses in children of women with unipolar and bipolar affective disorder

School-age children of unipolar depressed, bipolar, chronically medically ill, or normal women were diagnosed every 6 months for up to 3 years. Offspring of unipolar women had the highest rates of disorder at all evaluations, but children of bipolar and medically ill mothers also experienced significant rates of disorder. Observing diagnoses from both past lifetime and prospective follow-up assessments, it appeared that most children who had diagnoses had onsets in preadolescence and continued a chronic or intermittent course of disorder. Thus, risk to offspring of ill mothers is not transitory and indicates a pernicious course that commonly includes effective disorders alone or in combination with behavior and anxiety disorders.

Comparison of intracranial pressure between spina bifida patients and normal subjects using a non-invasive pressure assessment technique

A comparison of mean intracranial pressure (ICP) between 36 spina bifida patients and 24 patients with clinically normal ICP was undertaken. A new non-invasive method of assessing ICP was used throughout this study. The technique relates tympanic membrane displacement to ICP and has been shown to be a reliable measure of mean ICP by comparison with direct measures via ventricular catheters and reservoirs, subdural catheters and lumbar punctures. Using this non-invasive method the results of this study indicated that the patients with spina bifida and without a ventricular shunt have a higher than average mean ICP. The results demonstrated a significant difference (99.9%) in the measures of ICP between the spina bifida and normal populations. A significant difference (99.9%) in the ICP was also found between patients with spina bifida and with and without ventricular shunts, and thus presumably those with and without diagnosed hydrocephalus. It is suggested that patients with spina bifida and without ventricular shunts probably have higher than average mean ICP when compared with the normal population.

Observations of interactions of depressed women with their children

Dysfunctional interactions between mothers with major affective disorders and their children may contribute to the children's high risk of disorder. This study investigated the behavior of mothers with recurrent unipolar depression, bipolar disorder, or chronic medical illness and of normal subjects toward their children during a directly observed conflict discussion task. In addition, lifetime history of depression, current mood, and chronic stress were investigated as predictors of maternal interaction. Unipolar depressed women displayed relatively more negative, less positive, and less task-focused behaviour toward their children. Current mood and chronic stress, more than psychiatric history, contributed to the prediction of interaction style.

Cognitive vulnerability in children at risk for depression

Cognitive, developmental, and psychodynamic theories all hypothesize that negative self-concepts acquired in childhood may induce vulnerability to depression. Children at risk because of maternal major affective disorder, compared with children of medically ill and normal mothers, were examined for evidence of negative cognitions about themselves, and were found to have more negative self-concept, less positive self-schemas, and more negative attributional style. It was further predicted that negative cognitions about the self would be related to maternal depression and chronic stress, and to the quality of perceived and actual interactions with the mother. In general, the predicted associations were obtained, supporting speculations about how maternal affective disorder is associated with stress and with relatively negative and unsupportive relationships with children that in turn diminish children's self-regard.

Maternal affective disorders, illness, and stress: risk for children's psychopathology

Stressful circumstances that covary with maternal affective disorder may account for some of the risk to children for psychological dysfunction. Children (ages 8-16) of mothers with unipolar or bipolar disorders were compared with children of mothers who had chronic medical illness and children of normal mothers. Comparisons included Kiddie-SADS (Schedule for Affective Disorders and Schizophrenia) diagnoses and evaluations of behavior problems, school functioning, and social competence. Compared to the other groups, children of mothers with affective disorder (especially unipolar) had high rates of diagnosis. With the effects of chronic stress statistically controlled, psychosocial outcome variables showed fewer differences between groups but indicated particular impairment for children of unipolar mothers.