Development and evaluation of a standardized questionnaire for identifying adverse events in vaccine clinical trials

In vaccine trials, diary questionnaires or vaccination report cards (VRCs) are used extensively to collect complaints reported by subjects or guardians following vaccination. These have not been evaluated for accuracy or standardized to facilitate tolerability comparisons among vaccines.Objectives -(1) Develop standardized, age-specific VRCs for collecting self-reported adverse events (AEs) in trials; (2) Evaluate whether complaints elicited by nurse examinations or telephone interviews were missed by VRCs.Methods -Vaccine-trial databases, focus groups, experts and experienced nurses were used to develop paediatric and adolescent/adult VRCs. VRCs were evaluated at four sites. The primary outcome was subjects with AEs missed on the VRC and reported in nurse examinations (for injection-site reactions) or telephone interviews (for systemic complaints).Results -Of 855 subjects, 96.5% completed VRCs. For systemic complaints, 1.5% (12/812) reported both no complaint on VRCs and at least one complaint in telephone interviews. For injection-site reactions, 5.1% (53/1030) of injection sites had both no reaction reported on VRCs and had reactions noted by nurse examination. No missed AEs were rated as severe.Conclusion -The data suggest VRCs provide a practical and reasonably complete method of eliciting complaints following vaccination. Copyright (c) 2000 John Wiley & Sons, Ltd.

A phase I study of BMS-582664 (brivanib alaninate), an oral dual inhibitor of VEGFR and FGFR tyrosine kinases, in patients (pts) with advanced/metastatic solid tumors: Safety, pharmacokinetic (PK), and pharmacodynamic (PD) findings

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Background: Brivanib is an oral prodrug of BMS-540215, a dual tyrosine kinase inhibitor of VEGFR and FGFR signaling. Part A of this study defined an MTD of 800 mg qd (Abstract # 3051, ASCO 2006). Part B investigated expanded doses / schedules for safety, PK and PD. Methods: In Part B, sequential cohorts were treated with 320 mg qd, 800 mg 5 days on/2 off (800I), 800 mg qd (800C), or 400 mg bid. Available data are reported for pts treated at these doses in Part A + B. PK samples were obtained Days 1, 8 and 26. Tumor DCE- MRI parameters, transfer constant (Ktrans), area under the concentration-time curve - first 60 s post contrast injection (AUC60) were measured baseline X 2, Days 2, 8 and 26. Reproducibility was assessed by within pt %CV (wCV). Exposure-response analysis was performed using logistic regression. Serum ELISAs for soluble VEGFR2 and Collagen IV were measured at baseline, Days 8 and 26. Results: Fourteen, 9 and 18 pts were treated at 320, 800I and 800C, respectively. G3/4 AEs at 320, 800I, and 800C respectively were fatigue (21%, 0%, 22%), ↑ transaminase (8%, 11%, 17%), diarrhea (0%, 11%, 11%), hypertension (0%, 0%, 11%), platelets (8%, 0%, 11%). 800C had the greatest change in Ktrans, AUC60 and serum markers at Day 8 and 26 ( Table ). 800I had some recovery Day 2 to Day 8 and a smaller change at Day 26 than 800C. wCV for Ktrans and AUC60 was 26% and 22% respectively. The probability of DCE-MRI change increased with exposure (AUCtau) to BMS-540215. Conclusions: Brivanib has dose-proportional PK and a tolerable safety profile = 800C. PD changes were greatest at 800C. Some recovery in DCE-MRI effect after 2 day dosing break suggests continuous dosing is preferable for biological activity.

[Table: see text]

No significant financial relationships to disclose.

Overweight, obesity and girth of Australian preschoolers: prevalence and socio-economic correlates

OBJECTIVE

(1) To determine the prevalence of overweight and obesity in Australian 4-5-year-old children. (2) To investigate associations between socio-economic characteristics and (a) overweight/obesity and (b) waist circumference.

DESIGN

Cross-sectional population survey.

SETTING

Wave 1 (2004) of the Longitudinal Study of Australian Children.

PARTICIPANTS

Nationally representative sample of 4983 4-5-year-old children (2537 boys and 2446 girls; mean age 56.9 months (s.d. 2.64 months; range 51-67 months)).

MAIN OUTCOME MEASURES

Prevalence of overweight and obesity (International Obesity TaskForce definitions) and waist circumference (cm).

ANALYSIS

Prevalence estimates were obtained as weighted percentages. Uni- and multivariable ordinal logistic regression (using the proportional odds model) were used to assess associations between potential predictors and the risk of higher child body mass index status and a multivariable linear regression model to assess relationships between the same potential predictors and waist circumference.

RESULTS

15.2% of Australian preschoolers are estimated to be overweight and 5.5% obese. In univariate analyses, seven of the 12 variables were associated with higher odds of being in a heavier body mass index category. In a multivariable regression model, speaking a language other than English (particularly for boys), indigenous status and lower disadvantage quintile were the clearest independent predictors of higher body mass index status, with children in the lowest quintile of social disadvantage having 47% higher odds (95% CI 14, 92%) of being in a heavier body mass index category compared to those in the highest quintile. Waist circumference was not related to any socio-economic variable.

CONCLUSIONS

This nationally representative survey confirms high rates of overweight and obesity in preschoolers throughout Australia. The recent emergence of a substantial socio-economic gradient should bring new urgency to public health measures to combat the obesity epidemic.

The Na+/H+ Exchanger: A Target for Cardiac Therapeutic Intervention

The Na(+)/H(+) exchanger (NHE) is a ubiquitous protein present in mammalian cells. In higher eukaryotes this integral membrane protein removes one intracellular H(+) for one extracellular Na(+) protecting cells from intracellular acidification. NHE is of essential importance in the myocardium. It prevents intracellular acidosis that inhibits contractility. NHE also plays a key role in damage to the mammalian myocardium that occurs during ischemia and reperfusion and is involved in hypertrophy of the myocardium. NHE is composed of a membrane bound domain of approximately 500 amino acids plus a hydrophilic regulatory cytoplasmic domain of approximately 315 amino acids. The NHE1 isoform is the only significant plasma membrane isoform present in the myocardium. The activity of NHE1 is elevated in animal models of myocardial infarcts and in left ventricular hypertrophy. During ischemia and reperfusion of the myocardium, NHE activity catalyzes increased uptake of intracellular sodium. This in turn is exchanged for extracellular calcium by the Na(+)/Ca(2+) exchanger resulting in calcium overload and damage to the myocardium. Numerous inhibitors of NHE have been developed to attempt to break this cycle of calcium overload. In animal models excellent success has been obtained in this regard. However in humans, clinical trials have resulted in only modest success and recently, significant detrimental side effects were note of one NHE inhibitor. The mechanisms by which these inhibitors affect NHE activity are presently being investigated and regions of the protein important in NHE activity and inhibitor efficacy are related but not identical. Future studies may develop superior inhibitors that may circumvent recently reported side effects. Recently, NHE inhibition has been shown to be remarkably effective in preventing hypertrophy in some animal models. Whether this proves to be a practical treatment for hypertrophy in humans has yet to be determined.

Mutability of p53 hotspot codons to benzo(a)pyrene diol epoxide (BPDE) and the frequency of p53 mutations in nontumorous human lung

p53 mutations are common in lung cancer. In smoking-associated lung cancer,the occurrence of G:C to T:A transversions at hotspot codons, e.g., 157, 248, 249,and 273, has been linked to the presence of carcinogenic chemicalsin tobacco smoke including polycyclic aromatic hydrocarbons suchas benzo(a)pyrene (BP). In the present study, we have used a highly sensitive mutation assay to determine the p53 mutation load in nontumorous human lung and to study the mutability of p53 codons 157, 248, 249, and 250 to benzo(a)pyrene-diol-epoxide (BPDE), an active metabolite of BP in human bronchial epithelial BEAS-2B cells. We determined the p53 mutational load at codons 157, 248, 249, and 250 in nontumorous peripheral lung tissue either from lung cancer cases among smokers or noncancer controls among smokers and nonsmokers. A 5-25-fold higher frequency of GTC(val) to TTC(phe) transversions at codon 157 was found in nontumorous samples (57%) from cancer cases (n = 14) when compared with noncancer controls (n = 8; P < 0.01). Fifty percent (7/14) of the nontumorous samples from lung cancer cases showed a high frequency of codon 249 AGG(arg) to AGT(ser) mutations (P < 0.02). Four of these seven samples with AGT(ser) mutations also showed a high frequency of codon 249 AGG(arg) to ATG(met) mutations, whereas only one sample showed a codon 250 CCC to ACC transversion. Tumor tissue from these lung cancer cases (38%) contained p53 mutations but were different from the above mutations found in the nontumorous pair. Noncancer control samples from smokers or nonsmokers did not contain any detectable mutations at codons 248, 249, or 250. BEAS-2B bronchial epithelial cells exposed to doses of 0.125, 0.5, and 1.0 microM BPDE, showed G:C to T:A transversions at codon 157 at a frequency of 3.5 x 10(-7), 4.4 x 10(-7), and 8.9 x 10(-7), respectively. No mutations at codon 157 were found in the DMSO-treated controls. These doses of BPDE induced higher frequencies, ranging from 4-12-fold, of G:C to T:A transversions at codon 248, G:C to T:A transversions and G:C to A:T transitions at codon 249, and C:G to T:A transitions at codon 250 when compared with the DMSO-treated controls. These data are consistent with the hypothesis that chemical carcinogens such as BP in cigarette smoke cause G:C to T:A transversions at p53 codons 157, 248, and 249 and that nontumorous lung tissues from smokers with lung cancer carry a high p53 mutational load at these codons.

Medical student interviewing skills and mother-reported satisfaction and recall

BACKGROUND

Providing feedback to medical students about their interviewing skills is an important component of teaching programmes. There is very little information about mothers' views of medical student consultations in paediatrics, and in particular about what mothers consider to be the key elements of a successful consultation. Patient-centred interviewing is a model which emphasizes the active seeking of patient views. In association with appropriate clinical skills, it is reported to promote improved health outcomes.

OBJECTIVES

To examine whether greater medical student clinical competence and more frequent use of patient-centred techniques is associated with higher maternal satisfaction, higher maternal rating of the medical student's interpersonal skills, and greater maternal recall of relevant diagnosis and treatment recommendations.

METHOD

Two standardized 'medical student' videotaped interviews were created based on actual senior medical student consultations. Interview A demonstrated both higher student clinical competence and higher patient-centredness compared with interview B. Both videotaped interviews were viewed and then rated, using a questionnaire, by 11 mothers attending a teaching general practice.

RESULTS

Significantly higher mean scores, indicating greater maternal satisfaction, were associated with interview A (P < 0.01 for all measures). Accurate recall for diagnosis and management was also significantly greater after interview A (mean diagnosis recall, interview A 35%, interview B 14%, P < 0.01; mean management recall, interview A 95%, interview B 57%, P < 0.01).

CONCLUSIONS

Maternal satisfaction and recall were higher following a more clinically competent and patient-centred medical student interview. Maternal ratings of student interviews could be used as an additional method of assessment as well as providing feedback to medical students on their interview skills development.

Body surface area as a determinant of pharmacokinetics and drug dosing

Body surface area (BSA) was introduced into medical oncology in order to derive a safe starting dose for phase I studies of anticancer drugs from preclinical animal toxicology data. It is not clear however, as to why dosing by BSA was extended to the routine dosing of antineoplastic agents. Several formulas exist to estimate BSA, but the formula derived by DuBois and DuBois is the one used in adult medical oncology. This formula was derived based on data from only nine patients; subsequent attempts to validate the formula have found the DuBois formula to either over or underestimate the actual determined BSA. While cardiac output does correlate with BSA, the relationship between BSA and other physiologic measures relevant for drug metabolism and disposition, such as, renal and hepatic function, is weak or nonexistent. Further only epirubicin, etoposide, and carboplatin have been studied to determine if dosing by BSA would reduce interpatient variability, and none of these drugs were found to have significant relationships between their pharmacokinetics and BSA. Future clinical trials of new agents should not presume that dosing based on BSA reduces interpatient variability. Studies should examine the role, if any, BSA has in dosing new chemotherapeutic agents in initial phase I studies.

Increased p53 mutation load in nontumorous human liver of wilson disease and hemochromatosis: oxyradical overload diseases

Hemochromatosis and Wilson disease (WD), characterized by the excess hepatic deposition of iron and copper, respectively, produce oxidative stress and increase the risk of liver cancer. Because the frequency of p53 mutated alleles in nontumorous human tissue may be a biomarker of oxyradical damage and identify individuals at increased cancer risk, we have determined the frequency of p53 mutated alleles in nontumorous liver tissue from WD and hemochromatosis patients. When compared with the liver samples from normal controls, higher frequencies of G:C to T:A transversions at codon 249 (P < 0.001) and C:G to A:T transversions and C:G to T:A transitions at codon 250 (P < 0.001 and P < 0.005) were found in liver tissue from WD cases, and a higher frequency of G:C to T:A transversions at codon 249 (P < 0.05) also was found in liver tissue from hemochromatosis cases. Sixty percent of the WD and 28% of hemochromatosis cases also showed a higher expression of inducible nitric oxide synthase in the liver, which suggests nitric oxide as a source of increased oxidative stress. A high level of etheno-DNA adducts, formed from oxyradical-induced lipid peroxidation, in liver from WD and hemochromatosis patients has been reported previously. Therefore, we exposed a wild-type p53 TK-6 lymphoblastoid cell line to 4-hydroxynonenal, an unsaturated aldehyde involved in lipid peroxidation, and observed an increase in G to T transversions at p53 codon 249 (AGG to AGT). These results are consistent with the hypothesis that the generation of oxygen/nitrogen species and unsaturated aldehydes from iron and copper overload in hemochromatosis and WD causes mutations in the p53 tumor suppressor gene.

Applying workflow analysis tools to assess immunization delivery in outpatient primary care settings

BACKGROUND

As health care organizations face increasing pressure to institute quality assurance activities, the already-underfunded community clinics that treat the poor and underserved are challenged to perform these activities within tight constraints of human and financial resources. With pediatric immunizations as a marker, a workflow observation tool was used to identify causal processes affecting immunization delivery.

METHODS

Ten clinics and five private practices, located in areas designated as health professional shortage areas, participated in the study, gaining access to a tool that would have been unaffordable to them from the private sector. Trained observers followed families through the clinic, using a 127-item workflow observation form--the Observational Checklist of Patient Encounters (OCPE)--assessing discrete activities that families encountered during the checkin/pre-exam, exam, discharge, and billing processes. A convenience sampling of the targeted population--children younger than three years of age--included observations of scheduled acute, scheduled well-child, follow-up, and walk-in visits. In the feedback session, a summary of each clinic's immunization delivery patterns was presented, with an emphasis on the individual health center's operational issues.

RESULTS

The workflow observation tool was used to identify operational errors affecting both clinical and fiscal processes in each of the clinics that had not been previously apparent to either clinic management or the quality improvement (QI) teams.

DISCUSSION

Feedback addressed and encouraged process-oriented improvements in response to the workflow observations, which were incorporated into the clinics' QI procedures. Twelve of the 15 clinics have formed process action teams to address QI issues on an ongoing basis.

Lipid-lowering therapy after coronary revascularization

Atherosclerosis is often asymptomatic, unrecognized, and undertreated. Lumen irregularities are important angiographic findings that should be addressed aggressively through risk factor modification, medical therapy, and coronary revascularization. Both angiographic and clinical benefits have been demonstrated with lipid reduction therapy in randomized clinical trials. Coronary revascularization is indicated for symptom relief and improvement in quality of life in patients with acute coronary syndromes at "intermediate" and "high" risk of subsequent death or myocardial infarction. In patients following percutaneous coronary intervention (PCI), future cardiac events may be related to lumen renarrowing or to progression of atherosclerotic disease at sites remote from the site of coronary revascularization. The time course of restenosis is relatively self-limiting, generally occurring within 6-12 months after the procedure. Clinical events occurring > 1 year after PCI generally relate to new lesions or progression of existing atherosclerotic disease. Patients with diabetes mellitus may be at higher risk for late coronary events than nondiabetic patients. In post-coronary artery bypass surgery (CABG) patients, the majority of late events relate to degeneration of saphenous vein grafts. Lipid lowering therapy after coronary revascularization has been shown to prevent clinical events related to plaque instability and inhibit progression of saphenous vein graft disease. Thus, there are 2 goals in management of patients with symptomatic coronary artery disease: (1) to relieve the flow-limiting stenosis, and (2) to prevent future clinical events with aggressive lipid lowering and modification of other risk factors. Patients, specialists, and primary care physicians each need to take accountability for this risk-factor modification.

A comparison of parent and adolescent reports describing the health-related quality of life of adolescents treated for cancer

Our objectives were to compare adolescent and parent ratings of the health-related quality of life (HRQL) of adolescents treated for cancer, to compare the HRQL of adolescents who were on treatment vs. the HRQL of those who were off treatment following their diagnosis with cancer and to assess the HRQL of adolescents who were at different points of time following their diagnosis with cancer. The HRQL of 70 adolescents (aged 10 to 18 years) consecutively attending the Women's and Children's Hospital Oncology Clinic in South Australia was assessed by means of standard questionnaires. Parents completed the Child Health Questionnaire, the Functional Status II(R) Questionnaire and the Impact-on-Family Scale. Adolescents completed the self-report version of the Child Health Questionnaire. In general, there was good agreement between parent and adolescent reports. However, parents of adolescents receiving active treatment for cancer reported that their illness was having a greater impact on the adolescents' physical functioning than was reported by the adolescents. The psycho-social functioning of adolescents in single-parent families was reported also by parents to be worse than that of adolescents in 2-parent families. The physical functioning of adolescents had only a weak relationship with parental status but a significant relationship with treatment status. Despite generally good agreement between parent and adolescent reports describing the HRQL of adolescents treated for cancer, it cannot be assumed that reports from parents are always an accurate reflection of the views of the adolescents. Studies examining the influence of independent factors on adolescents' HRQL must take into account differences in reports from these 2 informants and the possibility that key independent variables have differing relationships with the various domains which comprise adolescents' HRQL.

Childhood cancer: a 4-year prospective study of the psychological adjustment of children and parents

PURPOSE

The objective of this 4-year prospective study was to assess the psychological adjustment of children treated for cancer and their parents.

PATIENTS AND METHODS

Children aged 2 to 12 years with cancer diagnosed and their parents and families (n = 39) were assessed immediately after their diagnosis and then annually for the next 4 years. At each assessment, the psychological adjustment of the children and their families was compared with the adjustment of a cohort of children and families in the general community (n = 49).

RESULTS

Immediately after the diagnosis of cancer in the children, the children and their parents had significantly more psychological problems than children and parents in the community. However, at subsequent assessments, there was no difference in the number of psychological problems experienced by children and parents in the two groups.

CONCLUSIONS

In the longer term, the prevalence of psychological problems experienced by children treated for cancer and their parents does not differ from that found in children and parents in the general community. Future research should give greater attention to other aspects of the lives of children treated for cancer and their parents, including their broader health-related quality of life.

Standard dose (Mayo regimen) 5-fluorouracil and low dose folinic acid: prohibitive toxicity?

Despite the perception that standard 5-fluorouracil/folinic acid (5-FU/FA) (425 mg/m2 per day and 20 mg/m2 per day intravenously once daily x 5 every 4 or 5 weeks) is well tolerated, we have been impressed by toxicity seen and frequent need for dose modification. We performed a retrospective analysis to quantitate the proportion of patients experiencing toxicity and attempted to identify associated clinical characteristics. One hundred thirty-four patients received 5-FU/FA at standard doses described by the Mayo regimen. Patient characteristics were as follows: female 35%, median age 66 years, Eastern Cooperative Oncology Group performance status less than or equal to 2, 96%. Sixty-eight percent received chemotherapy for metastatic disease. Forty-seven patients (35%+/-8%) experienced significant toxicity and were unable to receive the second cycle as scheduled: 76% required dose reduction, 11% discontinued therapy (including two toxic deaths), 11% discontinued therapy during the first cycle, and 2% required dose delay. Logistic regression was used to explore the following as predictors of toxicity: age, sex, performance status, adjuvant versus metastatic setting, prior chemotherapy, prior radiation, mean corpuscular volume, red blood cell distribution width, albumin, alkaline phosphatase, aspartate aminotransferase, bilirubin, and calculated creatinine clearance. No clinical characteristic was found to predict toxicity. Only high bilirubin approached statistical significance. We conclude that standard 5-FU/FA, when used in the general population, is associated with significant toxicity. Known clinical characteristics are not helpful in predicting toxicity. The lack of previous formal phase I evaluation of this regimen of 5-FU/FA raises concerns regarding its safety and generalizability in clinical practice.

Failure to maintain the benefits of home-based intervention in adolescents with poorly controlled type 1 diabetes

OBJECTIVE

To determine whether a 6-month home-based intervention program in adolescents with poorly controlled diabetes improves metabolic control and whether benefits are maintained after the intervention.

RESEARCH DESIGN AND METHODS

Adolescents with a mean HbA1c of > 9.0% over the preceding 12 months received either routine care in a diabetes clinic and an ambulatory intervention for 6 months (n = 37) or routine care only (n = 32). A diabetes educator provided monthly home visits and weekly phone contact to educate and support the adolescents in setting goals for insulin adjustment, blood glucose monitoring, and target blood glucose range. There was no systematic change in the frequency of insulin injections. After the intervention, there was a 12-month follow-up when the intervention and control groups both received only routine care. Outcome measures were HbA1c and Diabetes Knowledge Assessment (DKN).

RESULTS

During the intervention, mean HbA1c fell (baseline: 11.1 +/- 1.3%, 6 months: 9.7 +/- 1.6%; P = 0.0001) and mean knowledge scores increased (P = 0.0001) in the intervention group but not in control subjects. However, this improvement in HbA1c and increase in knowledge was not maintained in the intervention group at 12- and 18-month follow-up assessments. Parents' knowledge scores also improved significantly from baseline levels in the intervention group at 6 and 12 months (P = 0.001, P = 0.005, respectively).

CONCLUSIONS

An ambulatory program improves metabolic control and knowledge in adolescents with poorly controlled type 1 diabetes; however, it is effective only while the intervention is maintained.

The treatment of distant metastases in soft tissue sarcoma

This article reviews the current standard approaches to the treatment of metastatic soft tissue sarcoma (STS) and evaluates new chemotherapy agents and novel approaches. A computerized search strategy was used to identify articles examining the role of chemotherapy and surgery in metastatic STS, which were published between January 1992 and December 1998. This search was supplemented by key articles from our files published before 1992. In selecting articles for inclusion in this review, emphasis was placed on randomized data and novel approaches. Only three agents-doxorubicin, ifosfamide, and dacarbazine-have shown significant activity in metastatic STS. Numerous studies have examined the efficacy and toxicity of combining the known active agents in standard doses or in high doses with cytokine support. Promising results, in terms of increased response rates, often have not been reproduced in randomized trials, and there is no convincing evidence of enhanced overall survival. New regimens should be evaluated in randomized trials incorporating quality-of-life endpoints. High-dose chemotherapy with bone marrow/stem cell rescue remains an investigational procedure of uncertain efficacy. Pilot studies have established the feasibility of intraperitoneal chemotherapy, after cytoreductive surgery, in patients with peritoneal sarcomatosis. To date, the efficacy of this approach has not been validated in phase II or III trials. The role of surgery in the treatment of isolated pulmonary metastases is well established. Results of small series raise the possibility that resection of hepatic metastases is beneficial in selected patients. Current chemotherapy options for patients with STS are limited. There is reason to hope that the situation will change with the further development of new agents that have novel and specific mechanisms of action.

The role of the family for behavioral outcome in children and adolescents following traumatic brain injury

This study assessed the behavioral outcome of 51 children with traumatic brain injury (TBI) up to 2 years following injury. Children with severe injuries, but not those with mild or moderate injuries, were reported by parents to have a greater incidence of behavior problems following TBI. Regression analyses indicated that the presence of a partner for the primary caregiver of the child and the acute emotional reaction of the parent to the injury were both predictive of child behavioral outcome, although not by 2-year follow-up. These findings suggest that parental coping resources may impact on the development of child behavioral sequelae following TBI, emphasizing the role of the family in the child's response and the importance of supportive intervention.

The role of the family for behavioral outcome in children and adolescents following traumatic brain injury

This study assessed the behavioral outcome of 51 children with traumatic brain injury (TBI) up to 2 years following injury. Children with severe injuries, but not those with mild or moderate injuries, were reported by parents to have a greater incidence of behavior problems following TBI. Regression analyses indicated that the presence of a partner for the primary caregiver of the child and the acute emotional reaction of the parent to the injury were both predictive of child behavioral outcome, although not by 2-year follow-up. These findings suggest that parental coping resources may impact on the development of child behavioral sequelae following TBI, emphasizing the role of the family in the child's response and the importance of supportive intervention.

Measuring the success of the Arkansas Health Care Access Foundation

This report is an attempt to measure the effectiveness of the Health Care Access Program and to study the demographic elements of the patient population served. The study involved a two-pronged approach. By polling both physicians and patients regarding their experiences with AHCAF, we can form conclusions about its effectiveness. In addition, demographic information regarding patient make-up and physician participation in regional areas can serve as a resource for strategic management of the program.

The use of alternative therapies by children with asthma: a brief report

OBJECTIVE

To identify the nature and prevalence of alternative therapies used by children with asthma attending a children's hospital.

METHODOLOGY

Subjects consisted of a consecutive series of 51 children with asthma aged 1-6 years who were attending the Women's and Children's Hospital, South Australia. Parents of the children completed a questionnaire describing the use of alternative therapies by the children.

RESULTS

Approximately 55% of children used alternative therapies for asthma management. Therapies used most commonly were massage, relaxation exercises, diet therapy and vitamins. There was no significant difference in the age, asthma severity, length of time since diagnosis or presence of another illness amongst children who did or did not use alternative therapies.

CONCLUSIONS

A substantial proportion of children with asthma who attend paediatric clinics use alternative therapies. Paediatricians should be aware of this and be prepared to discuss alternative therapies with parents. This may facilitate more open doctor-patient relationships and better management of children's asthma.

PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States

OBJECTIVE

The authors' goal was to describe the characteristics of posttraumatic stress disorder (PTSD) symptoms on resettlement in the United States and at 1-year follow-up among Bosnian refugees as well as possible factors affecting the PTSD symptom profile among these refugees.

METHOD

They used standardized instruments to assess 34 Bosnian refugees for PTSD at resettlement in the United States and 1 year later.

RESULTS

Fifteen of the refugees were diagnosed with PTSD at 1-year follow-up, compared with 25 at initial assessment. The average PTSD severity score at follow-up was 12.5, compared with 20.6 at initial assessment. At 1-year follow-up, 25 of the refugees experienced a decrease in severity of PTSD symptoms, one remained the same, and eight experienced an increase in severity. Older refugees were significantly more likely to have PTSD than younger refugees, and older refugees had more severe symptoms.

CONCLUSIONS

The level of PTSD diagnosis and symptoms in Bosnian refugees remained substantial 1 year after their resettlement in the United States, although there were notable overall decreases. Older refugees appeared to be at greater risk.

Individual change after genocide in Bosnian survivors of "ethnic cleansing": assessing personality dysfunction

The authors used the SCID-DES (disorders of extreme stress) instrument to assess for personality change in Bosnian survivors of "ethnic cleansing." Twenty four refugees underwent systematic, trauma-focused, research assessments, including the SCID-DES interview. Overall, this group of Bosnian survivors had been severely traumatized as a result of the Serbian nationalists' genocide. However, no subject met diagnostic criteria for DES. The SCID-DES yields far lower rates of trauma-related personality change in Bosnian survivors of genocide than in adult survivors of prolonged early life traumas. Therefore, the DES construct may have better application to prolonged, interpersonal, early life traumas than to the prolonged, communal traumas of genocide.

Childhood cancer: a two-year prospective study of the psychological adjustment of children and parents

OBJECTIVE

To follow prospectively the psychological adjustment of young children, parents, and families during the first 2 years after the children's diagnosis of cancer.

METHOD

Children aged 2 to 5 years with cancer diagnoses and their parents and families (n = 38) were assessed immediately after diagnosis, 1 year after diagnosis, and 2 years after diagnosis. At each assessment, the psychological adjustment of the children and their families was compared with the adjustment of a cohort of children and families in the general community (n = 39).

RESULTS

Children with cancer and their parents experienced significantly more emotional distress than children and parents in the community during the period immediately after diagnosis. However, the number of problems experienced by the children with cancer and their parents declined during the first year after the children's diagnosis and stabilized at a level comparable with that found among children and parents in the general community.

CONCLUSION

Although the results are consistent with reports that suggest that in the longer term the prevalence of psychological problems among children with cancer is similar to that found among children in the general community, they also highlight the considerable distress experienced by children and parents during the period immediately after the children's diagnosis.

Predictors and indicators of academic outcome in children 2 years following traumatic brain injury

Within the context of a longitudinal study investigating outcome for children following traumatic brain injury, this paper reports on the utility of neuropsychological testing in predicting academic outcome in children 2 years following traumatic brain injury (TBI). Twenty-nine school-age children who were admitted to hospital after TBI were assessed with a battery of neuropsychological and academic measures at 3 and 24 months postinjury. The neuropsychological battery included measures of memory, learning, and speed of information processing. Academic outcome was assessed in terms of post-TBI change in school placement. According to logistic regression analysis, change in placement from regular to special education at 2 years post-TBI was predicted by injury severity and by neuropsychological performance at 3 months post-TBI. Findings suggest that neuropsychological testing is useful in identifying children with special educational needs subsequent to TBI.

Diagnosis of perinatal human immunodeficiency virus infection by polymerase chain reaction and p24 antigen detection after immune complex dissociation in an urban community hospital

Results of polymerase chain reaction (PCR) and p24 antigen detection after immune complex dissociation (p24-ICD) were compared with antibody results after 18 months of age for human immunodeficiency virus (HIV) diagnosis in 345 prospectively followed, perinatally exposed infants. Of 59 infected and 286 uninfected infants tested at 1-6 months of age, sensitivity and specificity were, respectively, 100% and > 97% for PCR and 90% and > 97% for p24-ICD. Testing was done on > or = 2 occasions in the first 6 months of life in 43 infected infants; 77% had > or = 2 positive results with the same test. Of these infants, 68% had 2 positive p24-ICD tests. In uninfected infants, 96% had only negative tests; none had > 1 positive. By 6 months, all uninfected infants with > or = 2 PCR results could have been diagnosed. HIV status can be determined by PCR by age 6 months in most HIV-exposed infants. p24-ICD should not be used alone, because of its lower sensitivity, but may be useful in areas without advanced laboratory support.

Energy expenditure variations in soldiers performing military activities under cold and hot climate conditions

This study assessed the energetic status of soldiers exposed to intense physical activities in cold and warm weather. Thirty subjects participated in a two-phase study group A (n = 18) in the winter phase and group B (n = 12) in the summer phase. Energy expenditure (EE) was measured by the doubly labeled water technique; after a single, oral dosing of 2H(2)18O, daily urine samples were collected for 12 successive days. Energy intake (EI) was assessed from detailed food records analyzed by computerized food charts. Energy balance was calculated as the difference between EI and EE for each subject. Mean (+/- SE) daily EE was 4,281 +/- 170 and 3,937 +/- 159 kcal/day for the winter and summer groups, respectively. Daily EI was 2,792 +/- 124 kcal/day in group A and almost identical in group B. A negative energy balance of 1,422 +/- 163 kcal/day and 924 +/- 232 kcal/day (not significant) was calculated for groups A and B, respectively. Energy expenditure is primarily determined by the level of activity rather than by climate conditions; EI is insufficient to offset the high energy requirements under these conditions.

Lifetime exposure to environmental lead and children's intelligence at 11-13 years: the Port Pirie cohort study

OBJECTIVE

To examine the association between environmental exposure to lead and children's intelligence at age 11-13 years, and to assess the implications of exposure in the first seven years of life for later childhood development.

DESIGN

Prospective cohort study.

SUBJECTS

375 children born in or around the lead smelting town of Port Pirie, Australia, between 1979 and 1982.

MAIN OUTCOME MEASURE

Children's intelligence quotient (IQ) measured at 11-13 years of age.

RESULTS

IQ was inversely associated with both antenatal and postnatal blood lead concentrations. Verbal, performance, and full scale IQ were inversely related to blood lead concentration with no apparent threshold. Multivariate analyses indicated that after adjustment for a wide range of confounders, the postnatal blood lead concentrations (particularly within the age range 15 months to 7 years) exhibited inverse associations with IQ. Strong associations with IQ were observed for lifetime average blood lead concentrations at various ages. The expected mean full scale IQ declined by 3.0 points (95% confidence interval 0.07 to 5.93) for an increase in lifetime average blood lead concentration from 0.48 to 0.96 mumol/l (10 to 20 micrograms/dl).

CONCLUSION

Exposure to environmental lead during the first seven years of life is associated with cognitive deficits that seem to persist into later childhood.

Neuropsychological deficit and academic performance in children and adolescents following traumatic brain injury

Evaluated the utility of neuropsychological testing in predicting academic outcome in children 1 year following traumatic brain injury (TBI). Fifty-one school age children who were admitted to hospital after TBI were assessed with a battery of neuropsychological measures at 3 months postinjury. Academic achievement was assessed at 3 and 12 months postinjury. The neuropsychological battery included intelligence testing and measures of memory, learning, and speed of information processing. Academic outcome was assessed in terms of post-TBI changes in reading, spelling, and arithmetic; changes in teacher ratings of school performance; and change in school placement. According to logistic regression analysis, change in placement from regular to special education at 1-year post-TBI was predicted by injury severity and by neuropsychological performance at 3 months post-TBI. Findings suggest that neuropsychological testing is useful in identifying children with special educational needs subsequent to TBI.

Abdominal wall endometrioma in a laparoscopic trocar tract: a case report

Extrapelvic endometriosis often presents as an atypical, painful abdominal mass often referred to the surgeon for diagnosis and treatment. The majority of extrapelvic endometriosis is found in surgical scars. We present a patient with an abdominal wall endometrioma that occurred in a laparoscopy trocar tract. To our knowledge, this is the first such case reported in the surgery or gynecology literature. With the increasing use of laparoscopy for gynecologic and general surgery procedures, this problem will likely become more common. The general surgeon should know how to diagnose and treat endometriomas arising in laparoscopic trocar tracts.

Parent satisfaction with services in an emergency department located at a paediatric teaching hospital

OBJECTIVE

To evaluate parents' satisfaction with the services provided in an emergency department located at a paediatric hospital.

METHODOLOGY

A descriptive study in which the parents of children with non-life-threatening illnesses attending an emergency department completed a questionnaire describing their satisfaction with services in the department.

RESULTS

The majority of parents were satisfied with the services provided. However, less satisfied parents reported having to wait significantly longer before receiving medical attention than satisfied parents. Consistent with this finding, 77% of less satisfied parents reported that staff did not attend to their children's needs quickly enough and 62% felt that there were insufficient staff available to provide help. Twenty-nine per cent of the less satisfied parents reported that they did not know what was required for the ongoing care of their children after their discharge from the emergency department.

CONCLUSIONS

In order to address the concerns of less satisfied parents, emergency departments need to give careful attention to the maintenance of reasonable waiting times, the provision of adequate staffing, and the quality of staff-parent communication. Addressing these issues may improve the ongoing care of children after their discharge from emergency departments.

Paediatric hospital services: are we satisfying our adolescent patients?

This study evaluated the satisfaction of adolescents with general inpatient services in a paediatric hospital. The results suggest that the adolescents were generally satisfied with the services provided. However, a number of concerns were expressed about the physical characteristics of the wards, the day to day organization of the wards, and the lack of opportunity to participate in treatment planning. The results also suggest that adolescents' satisfaction with inpatient services will be improved if more attention is given to the physical surroundings in hospital wards and the level of privacy afforded to adolescent inpatients. Finally, the results draw attention to the importance adolescents place on being involved in decisions about their treatment planning. There is a great need for studies which focus on adolescents' perceptions of health services. This will help to ensure that adolescents receive services they perceive to be relevant and effective.

A preliminary study of factors that influence children's sense of competence to manage their asthma

This study identifies several factors that appear to influence children's sense of competence to manage their asthma. The study examined a consecutive series of 62 children and adolescents who had been admitted to hospital for management of their asthma. Self-reports rating their sense of competence to manage their asthma were obtained from all the children. In addition, reports were obtained of the children's motivation to achieve healthy functioning, their sense of control over their health, and parental knowledge of childhood asthma management. Results from the study suggest that older children, children who are more intrinsically motivated to achieve healthy functioning, and children with parents who are knowledgeable about asthma management feel more competent to manage their asthma. It is suggested that the effectiveness of asthma self-management programs for children may be improved if there is a better understanding of the psychological factors that influence children's sense of competence to manage their asthma.

Evidence of natural bluetongue virus infection among African carnivores

Bluetongue is an International Office of Epizootics List A disease described as the century's most economically devastating affliction of sheep. Bluetongue (BLU) viruses were thought to infect only ruminants, shrews, and some rodents, but recently, inadvertent administration of BLU virus-contaminated vaccine resulted in mortality and abortion among domestic dogs. We present evidence of natural BLU virus infection among African carnivores that dramatically widens the spectrum of susceptible hosts. We hypothesize that such infection occurred after ingestion of meat and organs from BLU virus-infected prey species. The effect of BLU virus on endangered carnivores such as the cheetah and African wild dog requires urgent investigation. Also, the role of carnivores in the epizootiology of this disease needs elucidation.

Varicella in children with perinatally acquired human immunodeficiency virus infection

Thirteen children with human immunodeficiency virus infection acquired perinatally and with varicella were identified. Clinical and epidemiologic information, including the use of varicella immune globulin and acyclovir, was obtained and testing for antibodies to varicella-zoster virus was done. The 13 children infected with human immunodeficiency virus had an uncomplicated clinical course, and many had a significant antibody response to varicella-zoster virus.

Longitudinal assessment of energy expenditure in pregnancy by the doubly labeled water method

Twelve women were studied before pregnancy and at 6-wk intervals from 6 to 36 wk gestation. Total energy expenditure (TEE) by the doubly labeled water method, basal metabolic rate (BMR), energy intake, and body composition were assessed on each occasion. There was substantial interindividual variation in the response to pregnancy. Mean total energy costs were as follows: delta BMR 112 +/- 104 MJ (range -53 to 273), delta TEE 243 +/- 279 MJ (range -61 to 869 MJ), and fat deposition 132 +/- 127 MJ (range -99 to 280 MJ). The mean total cost of pregnancy (cumulative TEE above baseline+energy deposited as fat and as products of conception) was 418 +/- 348 MJ (range 34-1192 MJ). This was much higher than current recommendations for incremental energy intakes. Self-recorded incremental intakes (208 +/- 272 MJ) seriously underestimated the additional costs. The variability in response emphasizes the problems in making prescriptive recommendations for individual women, because there is no way of predicting metabolic or behavioral responses to pregnancy.