Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders

The aim was to evaluate the efficacy of a manualized cognitive-behavioural program based on habit reversal for the management of chronic tic disorder (CTD) and habit disorder (HD). Forty-seven CTD and 43 HD received a 4-month treatment program. Thirty-eight (22 CTD, 16 HD) were placed on a waitlist control group, which subsequently received treatment. The treatment approach combined awareness training, relaxation (including modification of a tension-producing style of action), and habit-reversal training, with more general cognitive restructuring of anticipations linked to ticcing. Sixty-five percent of completers reported between 75 and 100% control over the tic. At 2-year follow-up, 52% rated 75-100% control. There were also significant changes post-treatment in measures of self-esteem, anxiety, depression and style of planning action. Successful tic/habit modification was associated in CTD and HD groups with successful change in style of planning action. There were no consistent differences in any outcome measures between CTD and HD groups.

Forensic evidence findings in prepubertal victims of sexual assault

OBJECTIVE

The American Academy of Pediatrics recommends forensic evidence collection when sexual abuse has occurred within 72 hours, or when there is bleeding or acute injury. It is not known whether these recommendations are appropriate for prepubertal children, because few data exist regarding the utility of forensic evidence collection in cases of child sexual assault. This study describes the epidemiology of forensic evidence findings in prepubertal victims of sexual assault.

METHODS

The medical records of 273 children <10 years old who were evaluated in hospital emergency departments in Philadelphia, Pennsylvania, and had forensic evidence processed by the Philadelphia Police Criminalistics Laboratory were retrospectively reviewed for history, physical examination findings, forensic evidence collection, and forensic results.

RESULTS

Some form of forensic evidence was identified in 24.9% of children, all of whom were examined within 44 hours of their assault. Over 90% of children with positive forensic evidence findings were seen within 24 hours of their assault. The majority of forensic evidence (64%) was found on clothing and linens, yet only 35% of children had clothing collected for analysis. After 24 hours, all evidence, with the exception of 1 pubic hair, was recovered from clothing or linens. No swabs taken from the child's body were positive for blood after 13 hours or sperm/semen after 9 hours. A minority of children (23%) had genital injuries. Genital injury and a history of ejaculation provided by the child were associated with an increased likelihood of identifying forensic evidence, but several children had forensic evidence found that was unanticipated by the child's history.

CONCLUSIONS

The general guidelines for forensic evidence collection in cases of acute sexual assault are not well-suited for prepubertal victims. The decision to collect evidence is best made by the timing of the examination. Swabbing the child's body for evidence is unnecessary after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis.

Depressive symptoms in the late postpartum among low socioeconomic status women

BACKGROUND

Postpartum depression has been the focus of much research in the past 15 years, but little is known about factors associated with depression of longer duration or later onset. The purpose of this longitudinal study was to analyze the relationship between stressful life conditions and postnatal depression in a group of women of low socioeconomic status from the third week to the sixth month postpartum.

METHODS

Nulliparas who met criteria for low socioeconomic status were recruited from the prenatal care clinics of four Montreal hospitals. Questionnaires were verbally administered in the home at 30 weeks' gestation, at 3 and 9 weeks postpartum, and at 6 months postpartum. Blockwise multiple linear regression analyses were performed by entering predictor variables that included sociodemographic characteristics, chronic stressors, life events, and social support network.

RESULTS

Sixty-eight women participated in the study. At 6 months postpartum, 38.2 percent of the mothers had a Beck Depression Inventory score of 10 or more. After accounting for previous depression, analyses indicated that chronic stressors (maternal health problems, infant difficulty, lack of money for basic needs, frequent conflicts with network members) and poor social support (informational and emotional) were associated with postnatal depressive symptoms.

CONCLUSIONS

Health practitioners should recognize that high depressive symptomatology frequently occurs among low socioeconomic status first-time mothers at six months postpartum. Chronic stressors and inadequate social support are the most important factors associated with this problem.

Socio-environmental factors and postnatal depressive symptomatology: a longitudinal study

This study analyses the relationships between stressful life conditions and postnatal depressive symptomatology in a group of women of low socioeconomic status (SES) and a group of women of high SES from the third to the ninth week postpartum. Nulliparous pregnant women were recruited from the prenatal care clinics of four hospitals. Multiple linear regression analyses demonstrated that after accounting for SES group membership and depressive symptomatology during pregnancy, early postnatal chronic stressors (frequent conflictual episodes with network members, maternal health problems) and social support were linked to later postnatal depressive symptomatology.

Professional isolation and occupational stress in teachers

The aim of the study was to investigate the relationship between professional isolation of teachers and their occupational stress. A systematic random sample of 1,110 teachers in Quebec were administered French Canadian versions of the UCLA Loneliness Scale and Teacher Stress Inventory. Analysis gave, as expected, a positive and significant correlation between isolation and occupational stress. This highlights the importance of looking for ways to reduce professional isolation of teachers.

Medical conditions and the risk of motor vehicle crashes in men

OBJECTIVE

To determine whether men aged 45 to 70 years with any medical condition are at an increased risk of involvement as drivers in police-reported motor vehicle crashes.

DESIGN

Case-control study.

SETTING

Province-wide population-based sampling.

PARTICIPANTS

A total of 2504 drivers randomly selected from those involved as a driver in a motor vehicle crash (cases) and 2520 men not involved in a crash (controls) during a 6-month period.

DATA COLLECTION

The Societé de l'assurance automobile du Quebec (SAAQ) computerized files provided data on crashes, age, and medical conditions. A mailed questionnaire elicited information on usual mileage and driving conditions.

RESULTS

Data from the SAAQ files were obtained for all 5024 drivers. The overall response rate to the mailed survey was 35.5% with no statistically significant differences in the distribution of characteristics between respondents and nonrespondents. There was no increase in crude (odds ratio, 0.99; 95% confidence interval, 0.85-1.17) or age-adjusted risk of crashes for men with a medical condition in the entire sample of subjects (N = 5024). Among respondents to the mailed questionnaire only, men with a medical condition showed no increased crude risk of crashes (odds ratio, 0.99; 95% confidence interval, 0.76-1.27); no difference was observed after adjustment for age, mileage driven, driver behaviors, and sociodemographic characteristics (odds ratio, 0.91; 95% confidence interval, 0.64-1.31).

CONCLUSIONS

Unlike previous studies, the risk estimate was derived from a population-based sample of drivers and adjusted for age, mileage driven, driver behaviors, and sociodemographic characteristics in multivariate analyses. The adjusted estimates failed to show an increased risk of motor vehicle crashes for drivers with a medical condition.

Are drivers with CVD more at risk for motor vehicle crashes? Study of men aged 45 to 70

OBJECTIVE

To examine whether male drivers aged 45 to 70 years suffering from cardiovascular disease (CVD) are more likely to be involved in motor vehicle crashes (MVC) that are reported to the police.

DESIGN

Population-based case-control study.

SETTING

Data on drivers' ages and medical conditions were compiled from the Societé de l'assurance automobile du Québec's (SAAQ) computerized files. A questionnaire was mailed to all subjects to collect additional information on annual distances driven and various driving behaviours.

PARTICIPANTS

Age-stratified population-based random sample. Subjects were 2504 drivers involved in MVCs during a 6-month period; controls were 2520 drivers not involved in crashes.

MAIN OUTCOME MEASURES

Proportion of drivers with CVD involved in MVCs.

RESULTS

Response rate to the questionnaire was 35.5%. Analysis of the SAAQ files' entire sample of 5024 drivers showed that drivers suffering from CVD were less likely to be involved in MVCs (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.67 to 0.99) than drivers without CVD. Although the estimate of risk remains unchanged when adjusted for age, it becomes statistically insignificant. It also remains unchanged and statistically insignificant when adjusted for yearly distance driven and driver behaviour, as shown by responses to the questionnaire. Drivers suffering from CVD drove significantly less each year (8900 km) than drivers without medical conditions (13,000 km).

CONCLUSION

This study shows no increased risk of motor vehicle crashes for drivers suffering from CVD.

Head injuries in children from plastic hairbeads

BACKGROUND

Plastic hairbeads are often worn as decorative hair fasteners by children. Serious, penetrating head injuries may result from their use and have been observed in some children following a fall.

OBJECTIVE

The objective of this report is to describe the imaging findings in children who have sustained head injury while wearing plastic hairbeads.

MATERIALS AND METHODS

Three children with significant head injuries resulting from embedded hairbeads are described. Three additional cases of minor head injury reported to the Consumer Product Safety Commission are summarized.

RESULTS

One child sustained a minimally depressed skull fracture without brain injury. The second child required surgical repair of a depressed skull fracture complicated by a parenchymal hemorrhage and dural tear. A third child required surgical evacuation of an organized, liquefied epidural hematoma 2 weeks after an initial evaluation at an outside emergency room.

CONCLUSION

Children wearing plastic hairbeads are at risk for severe head injury following a fall. Caution must accompany their use.

[Social support network evolution after the birth of their first baby: comparison between lower and middle class mothers]

The social support networks of a group of low socio-economic status (S.E.S.) mothers (n = 87) and a group of higher S.E.S. mothers (n = 44) are described and compared at the 30th week of pregnancy and at the third week after the birth of their first baby. The evolution of the support networks for these two groups of mothers during this period is also examined. A modified form of the ASSIS from Barrera has been used to measure the social support network. Results show that, during pregnancy, the social support network of low-S.E.S. mothers is more restricted than that of higher S.E.S. mothers. Although the actual number of people around them after the birth of the baby did not increase, low-S.E.S. mothers said they felt a slight increase in the number of people available to give support in some way. They also reported that conflicts were more frequent with some of them. For higher S.E.S. mothers, all social network variables remained stable from pregnancy through the first postpartum month.

Chronic stressors, social support, and depression during pregnancy

OBJECTIVES

To analyze the relationships between stressful life conditions, social support, and depressive symptomatology during pregnancy in women of low socioeconomic status and a comparison group of women of higher socioeconomic status.

METHODS

Study participants were recruited from four hospital prenatal care clinics. Low socioeconomic status was defined as no more than 11 years of education and a household income below the poverty level. Higher socioeconomic status was defined as at least 12 years of education and a household income at least one and one-half times the poverty level. All subjects were nulliparous, over 18 years of age, and French-speaking. Questionnaires were administered verbally at the participants' homes during the 30th week of pregnancy, approximately. The Beck Depression Inventory was used to measure depressive symptomatology during the preceding 7 days.

RESULTS

Approximately 47% of the low socioeconomic status women and 20% of the higher socioeconomic status women scored 10 or more on the Beck Depression Inventory, indicating a depressive state. Multiple regression analysis demonstrated that chronic stressors (eg, financial and housing problems), negative life events, and inadequate social support were all linked to high depressive symptomatology during pregnancy.

CONCLUSION

During pregnancy, depressive symptoms are common, especially in women of low socioeconomic status, and are strongly related to socioenvironmental factors.

Controversies in maternity care: where do physicians, nurses, and midwives stand?

Through a mail survey in 1991, we compared the opinions of 597 physicians practicing obstetrics, 723 maternity care nurses, and 70 midwives from the province of Quebec, Canada, about selected maternity care issues, including the practice of midwifery. Results showed that divergent points of view existed between and within the three groups on many maternity care issues. Physicians were more divided over the routine use of obstetric intervention than the approach to care or their opinion about midwives. Midwives held more client-centered and less interventionist attitudes than nurses or physicians. Nurses were much more open to midwives than physicians, but 20 to 30 percent of physicians saw some advantages in legalizing the practice of midwifery. Physicians and nurses generally considered midwives as a greater professional threat to the other group than to themselves. The fact that many physicians were critical of current maternity care is difficult to reconcile with their general opposition to midwives. How and to what extent physicians will respond to women's desire for more humanized and less interventionist care remains an open question. Given the problems facing maternity care in North America, expanding midwifery services is an alternative to examine seriously.

Midwifery defined by physicians, nurses and midwives: the birth of a consensus?

OBJECTIVE

To describe the form of midwifery practice preferred by physicians practising obstetrics, nurses providing maternity care and midwives.

DESIGN

Mail survey conducted in 1991.

SETTING

Province of Quebec.

PARTICIPANTS

A systematic random sample of 844 physicians, 808 nurses and 92 midwives; 597, 723 and 92 respectively completed the questionnaire, for an overall response rate of 80%.

MAIN OUTCOME MEASURES

Midwife training options, range of responsibilities, location of midwifery care, relationship to other maternity care providers and degree of autonomy.

RESULTS

Most of the physicians, nurses and midwives surveyed agreed that if midwifery was legalized, midwives should have a university degree, provide basic care to women with normal pregnancy and delivery, provide prenatal and postnatal care in hospitals and community health centres, perform delivery in hospitals and work in close collaboration with the other maternity care professionals. Disagreement existed concerning the level of university training required, the need for training in nursing first, the scope of medical intervention performed by midwives, out-of-hospital delivery, the autonomy of midwives and control over their practice.

CONCLUSION

Some consensus on midwifery practice exists between physicians, nurses and midwives. In jurisdictions where opposition to midwives is strong, such consensus could serve as the starting point for the introduction of midwifery.

Diaphragmatic hernia masquerading as pneumothorax in two toddlers

In two separate incidents, two toddlers with no previous history of respiratory ailments presented to the emergency department of a children's hospital with progressive respiratory distress. Both children had unilateral lung findings on auscultation and initial chest radiographs that were consistent with a pneumothorax. Thoracostomy and chest tube insertion were performed during initial resuscitation efforts. In both cases, subsequent radiographs revealed that the stomach was located in the left hemithorax, suggestive of a diaphragmatic hernia. Nasogastric tube insertion relieved the respiratory distress of these two children. Recognition of the "acquired" congenital diaphragmatic hernia in the setting of extreme aerophagia or mild abdominal trauma may prevent unnecessary procedures during the resuscitation of children with acute respiratory distress and unilateral lung findings.

Mucosal histamine elimination and its effect on acid secretion in rabbit gastric mucosa

BACKGROUND

Rapid elimination of histamine near the oxyntic cells is important in the termination of the secretory response when the signal for histamine release is discontinued. The mechanism of this local process is still unclear.

METHOD

Gastric mucosal histamine elimination was, therefore, examined in fundic mucosa mounted in flux chambers and in dispersed mucosal cells.

RESULTS

[3H]histamine placed into the serosal chamber medium was transported across the mucosal tissue into the lumen, but a greater quantity was methylated to an inactive metabolite, Nt-methylhistamine, and preferentially released to the serosal chamber, the interstitial medium. Both processes were enhanced by increased substrate concentration. They were reduced by lowering the temperature and by sodium replacement. Inhibition of histamine methyltransferase suppressed histamine uptake and methylation and significantly increased histamine-stimulated acid secretion in the tissue preparation and in dispersed mucosal cells. The augmentation was reduced by an H2-receptor blocker.

CONCLUSION

Mucosal histamine methylation and the secretion of histamine into the gastric lumen removes histamine from the extracellular space effectively, reducing the histamine concentration near the oxyntic cell surface.

Cardiotoxic effects of astemizole overdose in children

Astemizole, a nonsedating antihistamine, caused a prolonged corrected QT interval, ventricular dysrhythmias, and atrioventricular heart block after overdose in five children. Cardiotoxic effects lasted an average of 2 1/2 days. Children poisoned with astemizole need emergent medical evaluation, a 12-lead electrocardiogram with calculation of the corrected QT interval, and continuous cardiac monitoring for 24 hours.

Histamine methyltransferase in dispersed cells from rabbit fundic mucosa

The cellular distribution of histamine N-methyltransferase was studied in rabbit gastric mucosa. The fundic mucosa was dispersed by collagenase treatment in Hanks' or calcium-free medium. In calcium-free medium, the number of dispersed cells/g wet tissue, as well as their viability was increased; histamine N-methyltransferase recovery was up to three-fold larger than in cells prepared in Hanks' medium. Furthermore, the calcium-free medium led to a greater acid secretory response, whereas the cellular pepsinogen content tended to be lower. Histamine N-methyltransferase activity was found in all cell fractions but was higher in the larger cell types. The enzyme activity showed only a partial correlation with either oxyntic or chief cells. These results indicate that the use of calcium-free medium to disperse and isolate rabbit mucosal cells improves cell quality. Histamine N-methyltransferase in the rabbit fundic mucosa, is found in more than one cell type, primarily the oxyntic and chief cells.

Contraindication for osmotic mini-pump in the abdominal cavity to study muscarinic cholinergic control of pancreatic enzyme secretion and muscarinic receptors

Alzet mini-pumps were used to study modulation of rat pancreatic muscarinic receptors and the acinic secretory response to long-term N-methylscopolamine (NMS) treatment. Infused intraperitoneally (i.p.), NMS, 25 mg.kg-1.day-1 for 14 days, resulted in a shift to the left in the amylase dose-response curve to carbamylcholine (Cch) and an increase in receptor concentration compared to saline-infused group. Compared to previously published control data [4,5] the saline-infused group exhibited desensitization with increased EC50 for secretion. An alternative mode of saline treatment, subcutaneous (s.c.) infusion showed normal pancreatic secretory response. Desensitization by i.p. saline infusion was prevented by NMS infusion. In conclusion, a foreign body such as a mini-pump in the abdominal cavity can cause desensitization of the pancreatic secretory function under neural cholinergic control.

Alteration of the rat exocrine pancreas after chronic scopolamine administration

N-Methyl scopolamine (NMS) 25 mg kg-1 was given to rats for 14 days as a single daily intraperitoneal injection or by constant infusion through osmotic minipumps placed in the abdominal cavity. The anticholinergic drug reduced significantly body and pancreatic weights, and total pancreatic DNA contents, an indication of tissue growth inhibition. Total enzyme and protein contents were however significantly increased with the drug infusion more efficiently than by the daily injection. It is suggested that pancreatic hypertrophy observed after NMS treatment can be ascribed partially to inhibition of enzyme release elicited by blocking the enteropancreatic reflex causing over a long period enzyme accumulation in the gland. In conclusion, chronic anticholinergic treatment resulted in pancreatic aplasia and hypertrophy and could serve as a good model to study muscarinic receptor modulation in the pancreas.