Variation in the clinical management of self-harm by area-level socio-economic deprivation: findings from the multicenter study of self-harm in England

BACKGROUND

We investigated disparities in the clinical management of self-harm following hospital presentation with self-harm according to level of socio-economic deprivation (SED) in England.

METHODS

108 092 presentations to hospitals (by 57 306 individuals) after self-harm in the Multicenter Study of Self-harm spanning 17 years. Area-level SED was based on the English Index of Multiple Deprivation. Information about indicators of clinical care was obtained from each hospital's self-harm monitoring systems. We assessed the associations of SED with indicators of care using mixed effect models.

RESULTS

Controlling for confounders, psychosocial assessment and admission to a general medical ward were less likely for presentations by patients living in more deprived areas relative to presentations by patients from the least deprived areas. Referral for outpatient mental health care was less likely for presentations by patients from the two most deprived localities (most deprived: adjusted odd ratio [aOR] 0.77, 95% CI 0.71-0.83, p < 0.0001; 2nd most deprived: aOR 0.80, 95% CI 0.74-0.87, p < 0.0001). Referral to substance use services and 'other' services increased with increased SED. Overall, referral for aftercare was less likely following presentations by patients living in the two most deprived areas (most deprived: aOR 0.85, 95% CI 0.78-0.92, p < 0.0001; 2nd most deprived: aOR 0.86, 95% CI 0.79-0.94, p = 0.001).

CONCLUSIONS

SED is associated with differential care for patients who self-harm in England. Inequalities in care may exacerbate the risk of adverse outcomes in this disadvantaged population. Further work is needed to understand the reasons for these differences and ways of providing more equitable care.

Can postural changes in spirometry in children with Duchenne muscular dystrophy predict sleep hypoventilation?

AIM

To explore the relationship between postural changes in lung function and polysomnography (PSG) in children with Duchenne muscular dystrophy (DMD).

METHODS

In this prospective cross-sectional study, children with DMD performed spirometry in sitting and supine positions. A control group of age and gender matched healthy children also underwent postural lung function testing. PSG was performed within six months of spirometry.

RESULTS

Seventeen children with DMD, aged 12.3 ± 3 years performed sitting spirometry. 14 (84%) performed acceptable spirometry in the supine position. Mean FEV1sit and FVCsit were 77% (SD ± 22) and 74% (SD ± 20.4) respectively, with mean% ΔFVC(sit-sup) 9% (SD ± 11) (range 2% to 20%), and was significantly greater than healthy controls 4% (n = 30, SD ± 3, P < 0.001). PSG data on the 14 DMD children with acceptable supine spirometry showed total AHI 6.9 ± 5.9/hour (0.3 to 29), obstructive AHI 5.2 ± 4.0/hour (0.2 to 10), and REM AHI 14.1 ± -5.3/hour (0.1 to 34.7). ΔFVC(sit-sup) had poor correlation with hypoventilation on polysomnography.

CONCLUSION

Children with DMD and mild restrictive lung disease showed greater postural changes in spirometry than healthy controls but lower supine spirometry was not predictive of sleep hypoventilation.

Cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England: a model-based retrospective analysis

Background

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.

Methods

A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.

Results

Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.

Conclusions

Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Use of non-invasive ventilation in children with congenital tracheal stenosis

INTRODUCTION

Congenital tracheal stenosis (CTS) is a rare airway condition characterized by complete tracheal rings. Most patients undergo a slide tracheoplasty, which greatly reduces mortality but significant morbidity remains. The assessment of sleep disordered breathing (SDB) and use of non-invasive ventilation (NIV) in these children has not been described.

AIM

To describe the presence of SDB and use of NIV in children diagnosed with CTS over a 10-year period (2005-2015).

DESIGN

Retrospective case series at a tertiary children's hospital.

RESULTS

There were 16 patients identified with CTS with a median [range] age at diagnosis of 2.5 months (0-9 months). One child died in the immediate post-operative period following a slide tracheoplasty, leaving 15 survivors. There were no later deaths during follow-up while using NIV for up to 3 years after surgery. Slide tracheoplasty was undertaken in (12/15) with long-segment tracheal stenosis. 3/15 patients had a short-segment tracheal stenosis and were managed conservatively. The use of NIV occurred in 10/15 (66.67%) patients, all of whom had long-segment CTS. Pre-operative polysomnography (PSG) showed a median (±SD) obstructive apnoea/hypopnoea index (OAHI) of 14.6/hr (±6.2) which reduced to 7.2/hour (±4.2) on NIV prior to slide tracheoplasty. The median oxygen desaturation index (ODI) before NIV use was 15.3 (±19.4) episodes/hour, which reduced to 6.3 (±11) on NIV. The median period of NIV use was 5 [1-24 months] months.

CONCLUSION

Patients with CTS have obstructed sleep disordered breathing. Trials of NIV are well-tolerated and improve sleep disordered breathing.

Contribution of cellulosic fibre filter on atmosphere moisture content in laser powder bed fusion additive manufacturing

Cellulosic materials are commonly used to manufacture the particulate filters used in laser powder bed fusion (LPBF) additive manufacturing (AM) equipment. An experimental approach has been used to calculate the moisture quantity and kinetics of sorption in a cellulosic filter at varying relative humidity (RH) levels. A prediction of the amount of moisture which can be theoretically held within a filter during storage before its use has been obtained. Subsequently, the quantity and the rate of moisture desorption which can be transferred into the build chamber during LPBF is presented. This work highlights the importance of filter storage and conditioning prior to use in additive manufacturing processing.

Can daytime measures of lung function predict respiratory failure in children with neuromuscular disease?

Neuromuscular disorders in children are a heterogeneous group of conditions with a variable age of presentation and overlapping clinical manifestations, many of which have progressive respiratory morbidity. Respiratory insufficiency occurs as a consequence of an imbalance between demands on the respiratory system and respiratory muscle capacity. Daytime measures of pulmonary function are used routinely in these children to assess respiratory status and monitor the consequences of the progression of muscle weakness. This review describes the current evidence for daytime pulmonary function tests and their ability to predict imminent respiratory morbidity.

Clinical guidelines for oral appliance therapy in the treatment of snoring and obstructive sleep apnoea

The purpose of this review is to provide guidelines for the use of oral appliances (OAs) for the treatment of snoring and obstructive sleep apnoea (OSA) in Australia. A review of the scientific literature up to June 2012 regarding the clinical use of OAs in the treatment of snoring and OSA was undertaken by a dental and medical sleep specialists team consisting of respiratory sleep physicians, an otolaryngologist, orthodontist, oral and maxillofacial surgeon and an oral medicine specialist. The recommendations are based on the most recent evidence from studies obtained from peer reviewed literature. Oral appliances can be an effective therapeutic option for the treatment of snoring and OSA across a broad range of disease severity. However, the response to therapy is variable. While a significant proportion of subjects have a near complete control of the apnoea and snoring when using an OA, a significant proportion do not respond, and others show a partial response. Measurements of baseline and treatment success should ideally be undertaken. A coordinated team approach between medical practitioner and dentist should be fostered to enhance treatment outcomes. Ongoing patient follow-up to monitor treatment efficacy, OA comfort and side effects are cardinal to long-term treatment success and OA compliance.

Airway, feeding and growth in infants with Robin sequence and sleep apnoea

OBJECTIVE

Robin sequence (RS) is associated with airway abnormalities that result in functional problems of obstructive sleep apnoea (OSA), feeding difficulties, and consequent poor growth. We evaluated the relationships between OSA severity, airway and feeding interventions, and weight at 12 months in infants with RS and OSA.

METHODS

Retrospective notes review of children with RS managed at our neonatal unit (1998-2010, inclusive).

RESULTS

Of 39 infants studied, 10 (25.6%) had mild/moderate OSA, and 29 (74.4%) severe. Infants with severe OSA required more airway interventions in hospital (82.8 vs 30.0%, p = 0.004) and at discharge (72.4 vs 20.0%, p = 0.007) than those with mild/moderate OSA; 30.0% of infants with mild/moderate OSA required continuous positive airway pressure (CPAP) during admission and 20.0% on discharge, but amongst those with severe OSA 82.8% required airway interventions as an inpatient, 17.2% underwent mandibular distraction osteogenesis, and 55.2% required CPAP on discharge. Those with severe OSA were also more likely to require tube feeding on discharge (89.7 vs 50.0%, p = 0.02). Overall, children were on a lower weight centiles at discharge compared to birth (-10.2 centiles) and at 12 months of age compared to birth (-14.8 centiles), but this occurred irrespective of OSA severity or need for airway interventions or tube feeding.

CONCLUSIONS

Infants with RS commonly have OSA, feeding and airway difficulties. Weight at 12 months appeared not to be influenced by OSA severity, feeding or airway problems, suggesting that current intervention/management strategy results in the severely affected infants growing as well as those affected less severely.

The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule

BACKGROUND

Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation.

METHOD

The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ⩾16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool.

RESULTS

A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94-95] and 21% specificity (95% CI 21-22), and had a positive predictive value of 30% (95% CI 30-31) and a negative predictive value of 91% (95% CI 90-92) in the derivation centres; it identified 83/92 of all subsequent suicides.

CONCLUSIONS

The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self-harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities.

Shared characteristics of suicides and other unnatural deaths following non-fatal self-harm? A multicentre study of risk factors

BACKGROUND

Mortality, including suicide and accidents, is elevated in self-harm populations. Although risk factors for suicide following self-harm are often investigated, rarely have those for accidents been studied. Our aim was to compare risk factors for suicide and accidents.

METHOD

A prospective cohort (n=30 202) from the Multicentre Study of Self-harm in England, 2000-2007, was followed up to 2010 using national death registers. Risk factors for suicide (intentional self-harm and undetermined intent) and accidents (narcotic poisoning, non-narcotic poisoning, and non-poisoning) following the last hospital presentation for self-harm were estimated using Cox models.

RESULTS

During follow-up, 1833 individuals died, 378 (20.6%) by suicide and 242 (13.2%) by accidents. Independent predictors of both suicide and accidents were: male gender, age 35 years (except accidental narcotic poisoning) and psychiatric treatment (except accidental narcotic poisoning). Factors differentiating suicide from accident risk were previous self-harm, last method of self-harm (twofold increased risks for cutting and violent self-injury versus self-poisoning) and mental health problems. A risk factor specific to accidental narcotic poisoning was recreational/illicit drug problems, and a risk factor specific to accidental non-narcotic poisoning and non-poisoning accidents was alcohol involvement with self-harm.

CONCLUSIONS

The similarity of risk factors for suicide and accidents indicates common experiences of socio-economic disadvantage, life problems and psychopathology resulting in a variety of self-destructive behaviour. Of factors associated with the accidental death groups, those for non-narcotic poisoning and other accidents were most similar to suicide; differences seemed to be related to criteria coroners use in reaching verdicts. Our findings support the idea of a continuum of premature death.

In-Vivo Assessment of Tissue Compatibility and Calcification of Bulk and Porous Silicon

The compatibility of both bulk and porous silicon at the subcutaneous site has been assessed for the first time, following ISO standard procedures. The in-vivo responses to implantation were monitored in the guinea pig and histopathological reactions evaluated at 1, 4, 12 and 26 weeks. Attention is focused here on the histological assessment protocols used, and the results demonstrating in-vivo evidence for good tissue compatibility, and porous Si bioactivity with regards calcification.

Screening for Obstructive Sleep Apnea in Preschool Children with Cleft Palate

Objective:

The objective of this study was to explore the prevalence, range of reported symptoms, and clinical risk factors of obstructive sleep apnea in preschool children with cleft lip and/or palate.

Design:

Questionnaires were distributed to parents/guardians of all children from birth to 5 years of age who were followed by the cleft clinic.

Results:

Questionnaire data and cleft classification were available for 248 children, with a mean age of 33.4 months. Obstructive sleep apnea was identified in 31.4% of the children. Only 29.5% of children with obstructive sleep apnea had undergone an investigation of these symptoms. The three most common symptoms reported in children with a questionnaire diagnosis of obstructive sleep apnea were (1) “heavy or loud breathing,” (2) “easily distracted,” and (3) “on the go” or “driven by a motor.” The only clinical risk factor associated with a questionnaire diagnosis of obstructive sleep apnea was the presence of a syndrome (χ2  =  3.5, p  =  .05). There were no significant differences in risk of obstructive sleep apnea by age, cleft classification, and surgical status.

Conclusion:

Preschool children with cleft lip and/or palate have a risk of obstructive sleep apnea that is as much as five times that of children without cleft. Obstructive sleep apnea appears to be underrecognized in this group of children. Further research is needed to investigate important risk factors for obstructive sleep apnea in children with cleft lip and/or palate.

Are children just small adults? The differences between paediatric and adult sleep medicine

Several important physiological and maturational changes occur in sleep development during the paediatric age range, particularly during infancy and in early childhood. As the pathology of sleep apnoea is superimposed onto a developing and often plastic physiological system, children often show a different pathophysiology to their adult counterparts. These factors need to be incorporated into the evaluation of a child's sleep problems. Particular attention should be paid to the developmental stage of the child. Investigation, interpretation and subsequent management provide further unique challenges and during successive reviews predicted normal changes must also be taken into account. This review article discusses the important physiological and maturational changes that occur in sleep during childhood, some common paediatric sleep conditions and their presentation and the appropriate evaluation and management of these conditions. In the course of the discussion, we have stressed important differences between paediatric and adult sleep medicine.

Management of paediatric thyroid carcinoma: recent experience with recombinant human thyroid stimulating hormone in preparation for radioiodine therapy

BACKGROUND

Thyroid carcinoma in children is rare and raises unique management issues. Although metastatic disease is more common in this age group, prognosis remains good with appropriate treatment. The aim of the study was to report recent experience in the management of differentiated thyroid carcinoma in children, especially in the use of radioiodine after recombinant human thyroid stimulating hormone (rhTSH) stimulation.

METHODS

Eight patients, aged 5-17 years (five were boys) presented following total thyroidectomy for thyroid carcinoma between May 2003 and June 2005. Seven had papillary carcinoma and one had follicular carcinoma. Five had known lymph node metastases and one had pulmonary metastases at presentation. Four patients had previously received therapeutic irradiation for malignancy. All eight underwent diagnostic iodine scans, seven with rhTSH stimulation. Seven went on to receive radioiodine treatment as hospital inpatients, comanaged by the paediatric and nuclear medicine units. The dosage of 131I ranged from 1.5 to 3.7 x 10(9) Bq. All except one were prepared by rhTSH stimulation.

RESULTS

Seven of eight patients had significant uptake in the neck on diagnostic scan and two had pulmonary abnormalities. Six of seven evaluable patients achieved complete thyroid ablation. Both patients with pulmonary abnormalities had scan resolution, although one of them only after a second radioiodine treatment. All patients had thyroxine replacement in doses to suppress TSH and all remain alive and well at time of carrying out this study.

CONCLUSION

Optimal management of paediatric thyroid carcinoma necessitates a multidisciplinary approach. Radioiodine therapy under rhTSH is an effective and safe adjuvant treatment in this special subgroup.

Outcome of children with neuromuscular disease admitted to paediatric intensive care

AIMS

To determine the outcome of children with neuromuscular disease (NMD) following admission to a tertiary referral paediatric intensive care (PICU).

METHODS

All children with chronic NMD whose first PICU admission was between July 1986 and June 2001 were followed up from their first PICU admission to time of study. The outcomes recorded were death in or outside of PICU, duration of PICU admission, artificial ventilation during admission and following discharge from PICU, and readmission to PICU.

RESULTS

Over 15 years, 28 children were admitted on 69 occasions. Sixteen (57%) children had more than one admission. The median duration of PICU admission was 4 days (range 0.5-42). Twenty three per cent of unplanned admissions resulted in the commencement of respiratory support that was continued after discharge from the PICU. Severity of functional impairment was not associated with longer duration of stay or higher PRISM scores. Ten children (36%) died, with four (14%) deaths in the PICU. A higher proportion of children with severe limitation of function were among children that died compared to survivors.

CONCLUSION

Most children with NMD admitted to the PICU recover and are discharged without the need for prolonged invasive ventilation. However, in this group of children, the use of non-invasive home based ventilation is common and they are likely to require further PICU admission.

Multiple cavitating pulmonary nodules and clubbing in a 12-year-old girl

We report on a 12-year-old girl with a prolonged history of cough and hemoptysis on three occasions. X-ray and computed tomography of the chest showed several cavitating lesions and mediastinal lymphadenopathy. Lung biopsy revealed nodular sclerosing Hodgkin's disease. Hodgkin's disease should be considered in the differential diagnosis of cavitating pulmonary lesions.

Sedation practices for Australian and New Zealand paediatric oncology patients

OBJECTIVES

Paediatric oncology patients often require repeated bone marrow aspirates and lumbar punctures. These procedures commonly require sedation and analgesia. The Australian and New Zealand College of Anaesthetists and the American Academy of Pediatrics have published guidelines that provide recommendations on monitoring and staffing requirements during sedation of paediatric patients. A survey was conducted of the oncology units in Australia and New Zealand in order to compare current practices with published guidelines.

METHODS

Telephone interviews were conducted with nursing or medical staff members.

RESULTS

Fourteen oncology units collectively perform approximately 130 procedures each week, of which 74% are performed under general anaesthesia. Of the remainder, most are performed using conscious sedation. Most units adhere to published recommendations regarding equipment and staffing during procedures performed under sedation. Only a minority of units follow guidelines regarding documentation; fasting requirements; observation and documentation of vital signs during and after the procedure; and obtaining informed consent for procedures performed using sedation.

CONCLUSION

Sedation practices among paediatric oncology units in Australia and New Zealand vary. None of the units fully adhere to published guidelines on childhood sedation. Paediatric oncology units should be familiar with the content of these guidelines and make an informed decision as to their usefulness, both in directing best clinical practice, and in supporting current practice in the event of medico-legal challenge.

Successful treatment of foscarnet-resistant herpes simplex stomatitis with intravenous cidofovir in a child

A leukemic child developed recurrent herpes simplex virus lesions shortly after receiving a bone marrow transplant and while taking acyclovir. The isolate was resistant to acyclovir and foscarnet in vitro. The lesions responded to a course of cidofovir.

Laryngo-pharyngeal carcinoma in childhood

Laryngo-pharyngeal carcinoma is rare in children. We present two cases of squamous cell carcinoma of the laryngopharynx in children less than 15 years of age. Both patients presented with a prolonged history of symptoms and extensive disease at diagnosis. Early visualisation the vocal cords with flexible larygnoscopy is important in children presenting with symptoms suggestive of laryngeal pathology. Long-term complications of definitive local therapy for laryngopharyngeal carcinoma are important in young children. Evidence from studies in adult patients suggests that adjuvant chemotherapy may play a role in laryngeal preservation in a select group of patients.

Prevalence of untreated asthma in a population sample of 6000 older adults in Bristol, UK

BACKGROUND

A study was undertaken to estimate the prevalence of untreated asthma in older adults.

METHODS

A cross sectional population based survey of 6000 men and women aged 65 years and over was performed in 21 general practices in north Bristol, south west England. The main outcome measure was untreated asthma as defined by a two stage process comprising a respiratory questionnaire (symptoms suggestive of asthma or doctor diagnosed asthma not receiving respiratory treatment) followed by lung function tests (significant reversibility following bronchodilators or corticosteroids and/or significant within day variability in peak expiratory flow).

RESULTS

4792 of the 6000 participants (80%) completed the respiratory questionnaire and, of those not receiving respiratory treatment, 55 reported a previous doctor diagnosis of asthma and a further 696 had symptoms suggestive of asthma. Lung function testing in 280 of 501 randomly selected individuals from these groups resulted in 38 being defined as having asthma and an estimated population prevalence for untreated asthma of 2.4% (95% CI 1.6% to 3.6%) in men and 1.2% (95% CI 0.7% to 2.1%) in women. Most subjects (84%) with untreated asthma had moderate or severe disease. Untreated asthma was most common in individuals with doctor diagnosed asthma (21%) and those with breathlessness or wheeze (13-20%).

CONCLUSION

Untreated asthma in the elderly is a common and important problem. Opportunistic use of appropriate lung function tests in older people with a history of doctor diagnosed asthma or wheeze or breathlessness at rest could identify untreated asthmatics who might benefit from treatment.

Prevalence of untreated asthma in a population sample of 6000 older adults in Bristol, UK

BACKGROUND

A study was undertaken to estimate the prevalence of untreated asthma in older adults.

METHODS

A cross sectional population based survey of 6000 men and women aged 65 years and over was performed in 21 general practices in north Bristol, south west England. The main outcome measure was untreated asthma as defined by a two stage process comprising a respiratory questionnaire (symptoms suggestive of asthma or doctor diagnosed asthma not receiving respiratory treatment) followed by lung function tests (significant reversibility following bronchodilators or corticosteroids and/or significant within day variability in peak expiratory flow).

RESULTS

4792 of the 6000 participants (80%) completed the respiratory questionnaire and, of those not receiving respiratory treatment, 55 reported a previous doctor diagnosis of asthma and a further 696 had symptoms suggestive of asthma. Lung function testing in 280 of 501 randomly selected individuals from these groups resulted in 38 being defined as having asthma and an estimated population prevalence for untreated asthma of 2.4% (95% CI 1.6% to 3.6%) in men and 1.2% (95% CI 0.7% to 2.1%) in women. Most subjects (84%) with untreated asthma had moderate or severe disease. Untreated asthma was most common in individuals with doctor diagnosed asthma (21%) and those with breathlessness or wheeze (13–20%).

CONCLUSION

Untreated asthma in the elderly is a common and important problem. Opportunistic use of appropriate lung function tests in older people with a history of doctor diagnosed asthma or wheeze or breathlessness at rest could identify untreated asthmatics who might benefit from treatment.

Aspergillus laryngotracheobronchial infection in a 6-year-old girl following bone marrow transplantation

Localised fungal infection of the larynx and tracheobronchial tree is extremely uncommon. We report the case of a 6-year-old girl with acute lymphocytic leukaemia, who developed symptoms of upper airways obstruction 6 months after a cord blood transplant. Bronchoscopy showed a pale plaque lesion in the larynx and tracheobronchial tree. Aspergillus fumigatus was cultured from a biopsy of the lesion. The patient was treated successfully with a prolonged course of amphotericin B and assessed with multiple surveillance bronchoscopies.

Sources of support for older people after discharge from hospital: 10 years on

AIMS OF THE STUDY

The aim of this research was to find out who supports older people at home after discharge from hospital and if sources of support have changed between the 1980s and the 1990s.

BACKGROUND

More and more older people are being discharged from hospital earlier and this creates additional pressures on families, community health and social services and the independent care sector. The research was concerned with how sources of support may have changed in a 10-year period.

METHODS

A comparison is made of two separate nonrandom samples, taken 10 years apart, of older people following discharge from hospital. Interviews were conducted in participants' homes to establish levels of dependence and the source of support given in response to the need for help with personal and domestic activities of daily living.

RESULTS

Although limited by the use of relatively small, nonrandom samples, the research found that proportions needing help with domestic activities were higher than those needing help with personal activities of daily living. Although dependence for help with bathing had declined between the 1980s and 1990s, help was still needed with bathing and dressing. Unmet need for help with bathing remained a problem in the 1990s. A growing role for home helps was identified, especially in personal care (bathing and dressing), where support from district nurses had declined. By the 1990s, home helps were doing less cooking and housework, including heavy laundry. Relatives were doing more of most domestic activities except shopping, which was being carried out by home helps.

CONCLUSIONS

The paper concludes by arguing that hospitals should consider if pressures to discharge older people more quickly might hinder the discharge planning process and communication between hospital and community sectors.

Observing washing and dressing of stroke patients: nursing intervention compared with occupational therapists. What is the difference?

This study sought to compare the interventions of qualified nurses with those of occupational therapists during morning care with the same population of stroke patients. Nonparticipant structured observation was used to identify the activities and interventions carried out by each of the two groups in a naturalistic care setting. Approval for the study was granted by the local ethics committee. In order to allow comparison between pairs, staff-patient interactions during morning care (n=10) were observed by a single researcher, firstly, with an occupational therapist and within 3 days of this, with a nurse. Twenty observation sessions were recorded in total during which time the activities, contacts and interactions were coded and recorded at 20-second intervals on a standard proforma. Analysis was undertaken using the Statistical Package for Social Sciences (SPSS) for windows. The results showed that occupational therapists used 'prompting and instructing' commands more than nurses and used facilitation techniques significantly more (P=0.0283). 'Supervision' interactions were preferred by nurses with 42.1% of their time spent performing this activity compared with 25.1% for occupational therapists. These results are limited to the group under observation. It is suggested that the reasons for the observed differences in intervention styles used by occupational therapists and nurses may be attributed to the approach taken to the assessment and treatment of stroke patients. This difference might be attributed to a lack of preparation for specialist neurological/neurovascular practices of nurses working in the field of stroke rehabilitation.

Deliberate self-harm and antidepressant drugs. Investigation of a possible link

BACKGROUND

It is not clear if the frequency of deliberate self-harm (DSH) is the same in patients taking different pharmacological classes of antidepressant drugs.

AIMS

To compare the frequency of DSH in patients who had been prescribed a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) prior to the DSH event.

METHOD

This was a prospective study in 2776 consecutive DSH cases attending an accident and emergency department. The incidence of DSH in TCA-treated cases and SSRI-treated cases is expressed as number of DSH events per 10 000 prescriptions of each antidepressant.

RESULTS

Significantly more DSH events occurred following the prescription of an SSRI than that of a TCA (P<0.001). The occurrence of DSH was highest with fluoxetine and lowest with amitriptyline.

CONCLUSIONS

Merely prescribing safer-in-overdose antidepressants is unlikely to reduce the overall morbidity from DSH.

Respiratory symptoms in older people and use of domestic gas appliances

BACKGROUND

Studies in children and young women have indicated an increased risk of respiratory illness in association with the use of domestic gas appliances, possibly caused by oxides of nitrogen generated when gas is burned. It is not known whether risks are similarly increased in older subjects.

METHODS

A questionnaire about respiratory symptoms in the past year and potential risk factors for respiratory disease was mailed to 6000 men and women aged 65 years and older who were selected at random from the lists of general practices in North Bristol, UK. Associations between symptoms and the use of gas appliances were examined by logistic regression with adjustment for age, sex, social class, and smoking habits.

RESULTS

Questionnaires were completed by 4792 (80%) of those mailed. The most common symptoms were exercise induced breathlessness, wheeze, or chest tightness (51%); wheeze (27%); morning phlegm (20%); and daytime breathlessness at rest (19%). In an analysis that included all subjects only weak associations were found with use of gas appliances, odds ratios all being 1.2 or less. The risks associated with use of a gas hob tended to be higher in women, with odds ratios of 1.36 (95% CI 1.01 to 1.83) for wheeze and 1.33 (95% CI 0.56 to 3.17) for morning chest tightness, but were lower than had been reported previously in younger women.

CONCLUSION

The absence of stronger associations cannot readily be explained by bias or confounding. Gas cookers and fires are unlikely to be an important cause of respiratory illness in the elderly. If they do cause such illness, the largest risks are likely to be in women who use gas hobs.

Testicular and paratesticular tumours in children: 30 years' experience

BACKGROUND

Testicular or paratesticular tumours in children are rare, making it difficult to achieve the best management for these life-threatening diseases. The aim of this study is to review patients during a 30-year period with these tumours and assess clinical aspects to improve management.

METHODS

The records of 68 patients from 1967 to 1996 were reviewed with respect to age at diagnosis, affected sites, presentation, clinical diagnosis, operation, pathology and prognosis.

RESULTS

The most common presentation was a painless scrotal mass (84%). The most common testicular tumour was mature teratoma (n = 27) followed by yolk sac tumour (n = 17). Thirteen patients had paratesticular rhabdomyosarcoma. Two teratocarcinomas, three leydig cell tumours, two sertoli cell tumours, one granulosa cell tumour, one fibroma, one gonadoblastoma, and one secondary tumour from acute myeloid leukaemia were found also. Testis-sparing surgery was performed in 21 of 33 patients with benign tumours (27 teratoma, three leydig cell tumours, two sertoli cell tumours, one fibroma), which caused no recurrence. Only two patients with rhabdomyosarcoma and one with mixed germ cell tumour died of their disease.

CONCLUSION

Recent combined therapy with surgery and chemotherapy against primary testicular and paratesticular tumours has improved prognosis. Testis-sparing surgery should be considered for benign tumours.

Prenatal detection of extra structurally abnormal chromosomes (ESACs): new cases and a review of the literature

We present 16 cases, 10 de novo and 6 familial, in which extra structurally abnormal chromosomes (ESACs) were diagnosed prenatally and identified by fluorescence in situ hybridization (FISH) studies with follow up from birth. We review the literature on prenatally diagnosed ESACs arising de novo and suggest a management protocol for these cases.

A new flap for reliable nasal reconstruction

OBJECTIVE

In this article, we describe a new flap for use in lower nasal reconstruction.

METHOD

This technique consists of a planned heminasal transposition rotation flap, with both laterally based and glabellar components. Esthetically favourable incisions are made to follow at the junction between the esthetic subunits.

RESULTS

Gratifying early results are achievable, resulting in little postoperative edema due to maintenance of laterally based lymphatic and venous outflow. Likewise, pleasing long-term outcomes have been noted in each of the ten patients in whom we have utilized this flap for nasal reconstruction. Complete flap survival has been noted in every patients.

CONCLUSIONS

Our experience with the use of this flap technique suggests that it provides consistently rewarding, esthetically pleasing results in patients with cutaneous defects of the lower half of the nose.

Quality of life in elderly patients with COPD: measurement and predictive factors

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity in old age. It leads to reduced quality of life (QoL), but the factors that contribute to this are less understood. There is no consensus on measurement of QoL in elderly COPD patients. We assessed (a) factors predicting QoL in elderly COPD out-patients and (b) specificity (SP), sensitivity (SEN), positive and negative predictive values (PPV and NPV) and repeatability of two disease-specific QoL instruments, the Chronic Respiratory Disease Questionnaire (CRQ) and the Breathing Problems Questionnaire (BPQ) in elderly people. All subjects also completed an ADL measure [Nottingham Extended ADL (NEADL)] and a measure of psychological well-being [Brief Assessment of Depression Cards (BASDEC)] as well as a 6-min walk test. Subjects comprised 96 (56 men) elderly out-patients with irreversible COPD aged 70-93 years (mean 78) who were clinically stable for > or = 6 weeks. Controls were 55 (23 men) aged 71-90 years (mean 78) with normal lung function. All were cognitively intact. Mean FEV1/FVC in COPD subjects was 45.5 (SE = 1.4)% and for controls was 71.4 (SE = 1.3)%. Repeatability was good for both BPQ and CRQ with no significant difference. There were no significant differences in specificity and positive predictive values between the two questionnaires but BPQ performed better than CRQ with regard to sensitivity (P = 0.02) and NPV (P < 0.001). A multiple regression analysis was used to identify variables that best predicted BPQ and CRQ in COPD subjects. For BPQ predictive values were NEADL (P < 0.0001); BASDEC (P < 0.0001); age (P < 0.0001); 6-min walk distance (P = 0.001); body mass index (P < 0.05); resting oxygen saturation (P < 0.05); and household composition (living alone or with relatives, P = 0.05). In contrast only the following predicted CRQ: NEADL, BASDEC and resting oxygen saturation. Sixteen per cent of the variance in BPQ was accounted for by NEADL score, 9% by BASDEC, 4% by age and 3% by 6-min walk distance (total r2 = 0.70). It was concluded that: (1) BPQ provides more valid assessment than CRQ of QoL in elderly COPD subjects; (2) severity of disease in terms of its impact on QoL is not predicted by lung function tests; (3) the most important determinants of QoL are ADL score and emotional status.

Correlation of MRI and CSF cytology in the diagnosis of medulloblastoma spinal metastases

BACKGROUND

Medulloblastoma frequently spreads to involve the spinal cord, which significantly reduces patient survival and determines whether chemotherapy is utilised and the dose of irradiation to the neuraxis. Staging is usually achieved by MRI of the spine and/or cytology of CSF, both methods having their limitations. Objective. To determine whether there is a correlation between CSF cytology and the demonstration of spinal metastases by MRI and whether CSF cytology is useful when spinal MRI is equivocal.

MATERIALS AND METHODS

All cases of medulloblastoma diagnosed at our hospital between 1992 and 1997 were identified. Of 26 cases, 11 presentations (age range 4 months to 12 years) had both CSF cytology (either from the cisterna magna or lumbar puncture) and spinal MRI. The MR studies were reviewed for the presence of metastases and the CSF cytology for the presence of tumour cells.

RESULTS

We found 100% correlation between MRI and CSF cytology for samples taken by lumbar puncture (four negative and three positive on both investigations). No correlation was demonstrated when CSF samples were taken from the cisterna magna. Conclusions. Our data suggest that lumbar CSF cytology may be useful when the MRI is equivocal for the presence of metastatic involvement of the spine by medulloblastoma.

Postoperative chemotherapy in children less than 4 years of age with malignant brain tumors: promising initial response to a VETOPEC-based regimen. A Study of the Australian and New Zealand Children's Cancer Study Group (ANZCCSG)

PURPOSE

Postoperative chemotherapy with indefinite postponement of radiation therapy in children < 4 years old with brain tumors was investigated in a multi-institutional study.

PATIENTS AND METHODS

From 1991 to 1995, 42 patients aged 3 to 47 months (median 20) with brain tumors were enrolled in a 2-phase chemotherapy protocol: 16 patients had medulloblastoma (MB); 8 had supratentorial primitive neuroectodermal tumor (PNET); 14 had ependymoma; and 4 had other tumors. The initial phase was comprised of 4 courses of the 3-drug regimen: vincristine (VCR), etoposide (VP-16), and intensive cyclophosphamide (CPA) in a previously reported schedule (VETOPEC). The continuation phase was comprised of 2-drug courses: A, CPA + VCR; B, cisplatin + VP-16; and C, carboplatin + VP-16, for a total duration of 64 weeks.

RESULTS

Response to VETOPEC was evaluable in 28 patients with postresection residual (25) and/or metastatic (1 M2, 6 M3) tumor. There were 9 complete responses (CR) and 9 partial responses (PR) with a combined CR + PR of 64% (95% confidence interval [CI] 44 to 81). In 12 evaluable patients with MB, CR + PR was 82% (48 to 98); in 6 patients with PNET, 50% (12 to 88); and, in 8 patients with ependymoma, 86% (42 to 99). Of 40 patients eligible for further analysis, 6 remain progression-free at a median of 30 months, 14 are alive at a median of 38 months, 29 have progressed at a median of 7 months (range, 2 to 37 months), and 26 have died. The progression-free and overall survival rates at 36 months are estimated to be 11% (95% CI 1 to 22) and 34% (18 to 50), respectively.

CONCLUSIONS

The initial response to the VETOPEC regimen is encouraging and warrants study of further dose escalation. Survival remains poor with current strategies in this high-risk population.

Recurrent rhabdomyosarcoma after 25 years: a possible association with estrogen and progestogen therapy

PURPOSE

We describe a patient with a late recurrence of rhabdomyosarcoma and review the relevant literature.

PATIENT AND METHODS

Recurrent rhabdomyosarcoma occurred in a young woman 25 years after initial presentation, with the onset of symptoms 3 months after commencing hormonal replacement therapy with estrogen and progestogen. The primary and recurrent tumors were immunocytochemically identical. The primary tumor was steroid receptor negative but the recurrent tumor was estrogen and progesterone receptor positive.

DISCUSSION

Estrogen priming can stimulate synthesis of progesterone receptors which may modulate mitotic activity, which suggests a functional role for receptor positive cells in modulating cell growth when sex hormone primed, with a possible tumor induction role of sex hormone replacement therapy.

CONCLUSION

The late tumor recurrence may have been induced by estrogen and progestogen treatment.

The computer synthesis of expressive faces

This paper presents a methodology for the computer synthesis of realistic faces capable of expressive articulations. A sophisticated three-dimensional model of the human face is developed that incorporates a physical model of facial tissue with an anatomical model of facial muscles. The tissue and muscle models are generic, in that their structures are independent of specific facial geometries. To synthesize specific faces, these models are automatically mapped onto geometrically accurate polygonal facial representations constructed by photogrammetry of stereo facial images or by non-uniform meshing of detailed facial topographies acquired by using range sensors. The methodology offers superior realism by utilizing physical modelling to emulate complex tissue deformations in response to coordinated facial muscle activity. To provide realistic muscle actions to the face model, a performance driven animation technique is developed which estimates the dynamic contractions of a performer’s facial muscles from video imagery.

The introduction of case management on a rehabilitation floor

An exchange for 1 day a week between a clinical nurse specialist and a lecturer gave rise to the opportunity to evaluate the introduction of case management on a newly created rehabilitation floor at an elderly care hospital. The aims of the study were to examine the feelings and concerns of new case managers, their conception of case management and their perceived educational needs. Qualitative research methods were employed to achieve the aims. Rigour was addressed, in part, through concurrent analysis of data with data collection, which encouraged probing of issues important to research participants. Thematic categories are presented under the headings: 'structure' and 'process'. The data collected revealed vividly that, as with any change, the people involved experienced anxieties and/or confusion over their new roles, but that some of the problems arose from the relocation of staff when the rehabilitation floor was established. Despite these difficulties, there was general enthusiasm for the potential of case management.

EWS/FLI-1 fusion transcript detection and MIC2 immunohistochemical staining in the diagnosis of Ewing's sarcoma

Ewing's sarcoma (ES) and other primitive peripheral neuroectodermal tumors (pPNETs) can present a significant diagnostic problem, as they may morphologically resemble other small round cell tumors (SRCTs) of childhood. However, ES/pPNET is known to carry a characteristic t(11;22)(q24;q12), the detection of which may aid diagnosis. The recent identification of the EWS and FLI-1 genes flanking the translocation break point has enabled reverse transcriptase-polymerase chain reaction (RT-PCR) to be used to detect the putative chimeric transcription factor mRNA produced by the fusion gene. We have assessed the RT-PCR method of detection by examining 40 cases of ES for the presence of EWS/FLI-1 transcripts. Twenty-six (76%) of the 34 cases with intact mRNA yielded fusion transcripts. Four different transcript sizes were detected and two tumors contained two transcripts of different size. No transcripts were detected in a control group of non-ES/pPNET SRCTs. Eight cases with intact mRNA were transcript negative. The MIC2 cell surface antigen, which is reported to be present in over 95% of ES/pPNETs, was present in 32 of 33 tumors (97%), including all 24 EWS/FLI-1 transcript-positive cases examined. Hence MIC2 is a useful screen for ES, with RT-PCR detection of t(11;22) being the optimal method for confirming the diagnosis.

A prisoner's dilemma experiment on cooperation with people and human-like computers

The authors investigated basic properties of social exchange and interaction with technology in an experiment on cooperation with a human-like computer partner or a real human partner. Talking with a computer partner may trigger social identity feelings or commitment norms. Participants played a prisoner's dilemma game with a confederate or a computer partner. Discussion, inducements to make promises, and partner cooperation varied across trials. On Trial 1, after discussion, most participants proposed cooperation. They kept their promises as much with a text-only computer as with a person, but less with a more human-like computer. Cooperation dropped sharply when any partner avoided discussion. The strong impact of discussion fits a social contract explanation of cooperation following discussion. Participants broke their promises to a computer more than to a person, however, indicating that people make heterogeneous commitments.

A prisoner's dilemma experiment on cooperation with people and human-like computers

The authors investigated basic properties of social exchange and interaction with technology in an experiment on cooperation with a human-like computer partner or a real human partner. Talking with a computer partner may trigger social identity feelings or commitment norms. Participants played a prisoner's dilemma game with a confederate or a computer partner. Discussion, inducements to make promises, and partner cooperation varied across trials. On Trial 1, after discussion, most participants proposed cooperation. They kept their promises as much with a text-only computer as with a person, but less with a more human-like computer. Cooperation dropped sharply when any partner avoided discussion. The strong impact of discussion fits a social contract explanation of cooperation following discussion. Participants broke their promises to a computer more than to a person, however, indicating that people make heterogeneous commitments.