Parkinson's Disease Caregiver Strain in Singapore

Background: Caregiver strain is recognized globally with Parkinson's disease (PD). Comparatively little is understood about caregiver burden and strain in Asia.

Objective: To investigate caregiver strain for families living with PD in Singapore, in light of international data.

Methods: Ninety-four caregivers were recruited via people living with idiopathic PD in Singapore. Caregiver strain was assessed using the Zarit Burden Interview (ZBI); health status was assessing using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). PD disability measures were the Unified Parkinson's Disease Rating Scale (UPDRS) and modified Hoehn and Yahr (1967) Scale.

Results: Primary caregivers of people living with PD in Singapore were mostly cohabiting spouses, partners or offspring. Around half employed foreign domestic helpers. Mean caregiving duration was 5.9 years with an average of eight hours per day spent in caregiving roles. Most care providers were comparatively healthy. Caregivers reported significant levels of strain which increased with greater level of disability (r = 0.36, n = 94, p < 0.001). Associations were significant between caregiver strain and scores on the UPDRS mentation, behavior, and mood subscales [r = 0.46, n = 94, p < 0.001, 95% CI (0.28, 0.60)]. High scores on the UPDRS activities of daily living subscale were associated with caregiver strain [r = 0.50, n = 94, p < 0.001, CI (0.33, 0.64)].

Conclusion: Most caregivers in this Singapore sample reported high levels of strain, despite comparatively good physical function. Caregiver strain in PD spans geopolitical and cultural boundaries and correlates with disease severity. These results support the need for better early recognition, education, and support for caregivers of people living with PD.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

Combination of flow cytometry and functional imaging for monitoring of residual disease in myeloma

The iliac crest is the sampling site for minimal residual disease (MRD) monitoring in multiple myeloma (MM). However, the disease distribution is often heterogeneous, and imaging can be used to complement MRD detection at a single site. We have investigated patients in complete remission (CR) during first-line or salvage therapy for whom MRD flow cytometry and the two imaging modalities positron emission tomography (PET) and diffusion-weighted magnetic resonance imaging (DW-MRI) were performed at the onset of CR. Residual focal lesions (FLs), detectable in 24% of first-line patients, were associated with short progression-free survival (PFS), with DW-MRI detecting disease in more patients. In some patients, FLs were only PET positive, indicating that the two approaches are complementary. Combining MRD and imaging improved prediction of outcome, with double-negative and double-positive features defining groups with excellent and dismal PFS, respectively. FLs were a rare event (12%) in first-line MRD-negative CR patients. In contrast, patients achieving an MRD-negative CR during salvage therapy frequently had FLs (50%). Multi-region sequencing and imaging in an MRD-negative patient showed persistence of spatially separated clones. In conclusion, we show that DW-MRI is a promising tool for monitoring residual disease that complements PET and should be combined with MRD.

Initial Medication Adherence-Review and Recommendations for Good Practices in Outcomes Research: An ISPOR Medication Adherence and Persistence Special Interest Group Report

BACKGROUND

Positive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription.

OBJECTIVE

Our objective was to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed.

METHODS

Using generic adherence terms, an international research panel identified IMA publications from 1966 to 2014. Their data sources were classified as to whether the primary source reflected the perspective of a prescriber, patient, or pharmacist or a combined perspective. Terminology and methodological differences were documented among core (essential elements of presented and unpresented prescribing events and claimed and unclaimed dispensing events regardless of setting), supplemental (refined for accuracy), and contextual (setting-specific) design parameters. Recommendations were made to encourage and guide future research.

RESULTS

The 45 IMA studies identified used multiple terms for IMA and operationalized measurements differently. Primary data sources reflecting a prescriber's and pharmacist's perspective potentially misclassified core parameters more often with shorter/nonexistent pre- and postperiods (1-14 days) than did a combined perspective. Only a few studies addressed supplemental issues, and minimal contextual information was provided.

CONCLUSIONS

General recommendations are to use IMA as the standard nomenclature, rigorously identify all data sources, and delineate all design parameters. Specific methodological recommendations include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.

A year in the life of the immunoglobulin superfamily

The superfamily of molecules with immunoglobulin-like domains has recently been gaining new members-largely on the basis of sequence homology. Here Alan Williams reviews this new work and reveals how the comparison of sequence patterns enables decisions on membership to be made. Accommodation of the new structures demands the provision of new categories, and forces the abandonment of the conserved disulphide bond as the last invariant characteristic of an immunoglobulin-type domain. They may, however, provide more dues to the origins and evolution of the immunoglobulin superfamily.

A systematic literature review of psychosocial and behavioral factors associated with initial medication adherence: a report of the ISPOR medication adherence & persistence special interest group

OBJECTIVES

Numerous factors influencing medication adherence in chronically ill patients are well documented, but the paucity of studies concerning initial treatment course experiences represents a significant knowledge gap. As interventions targeting this crucial first phase can affect long-term adherence and outcomes, an international panel conducted a systematic literature review targeting behavioral or psychosocial risk factors.

METHODS

Eligible published articles presenting primary data from 1966 to 2011 were abstracted by independent reviewers through a validated quality instrument, documenting terminology, methodological approaches, and factors associated with initial adherence problems.

RESULTS

We identified 865 potentially relevant publications; on full review, 24 met eligibility criteria. The mean Nichol quality score was 47.2 (range 19-74), with excellent reviewer concordance (0.966, P < 0.01). The most prevalent pharmacotherapy terminology was initial, primary, or first-fill adherence. Articles described the following factors commonly associated with initial nonadherence: patient characteristics (n = 16), medication class (n = 12), physical comorbidities (n = 12), pharmacy co-payments or medication costs (n = 12), health beliefs and provider communication (n = 5), and other issues. Few studies reported health system factors, such as pharmacy information, prescribing provider licensure, or nonpatient dynamics.

CONCLUSIONS

Several methodological challenges synthesizing the findings were observed. Despite implications for continued medication adherence and clinical outcomes, relatively few articles directly examined issues associated with initial adherence. Notwithstanding this lack of information, many observed factors associated with nonadherence are amenable to potential interventions, establishing a solid foundation for appropriate ongoing behaviors. Besides clarifying definitions and methodology, future research should continue investigating initial prescriptions, treatment barriers, and organizational efforts to promote better long-term adherence.

Health-Related Quality of Life of Caregivers of People with Parkinson's Disease in Singapore

Introduction:

To investigate the health-related quality of life (HRQoL) of caregivers for people with Parkinson's disease (PD) living in Singapore.

Methods:

A face-to-face survey was conducted with a cross-section of caregivers for people with PD. The caregivers were recruited from a PD clinic at an acute tertiary hospital in Singapore and from the members of the Singapore Parkinson's Disease Society. HRQoL was quantified using the SF-36v2® Health Survey, an internationally validated multi-purpose short-form health survey.

Results:

Ninety-four caregivers completed the survey (a response rate of 57.3%). The respondents were all above 21 years old, with most falling in the 51 and >61 years age range. Seventy-four of the respondents (78.7%) were female. As a whole, the caregivers scored lower in all 6 health domains compared to the general population (adjusted for age, gender and ethnic group) in Singapore. The were significant differences for the “Role Physical” and the “Role Emotional” domains, at 3.9 and 3.3 respectively. Caregivers had a much lower mental component summary (-2.4) when compared to the physical component summary (-1.6).

Conclusion:

It is important to identify the factors that influence the HRQoL of caregivers so that policies can be developed to lower the burden of PD on caregivers. Assessing the well-being of caregivers may help to identify individuals at risk. The well-being of caregivers has the potential to influence quality of life of people with PD.

Breastfeeding promotion for infants in neonatal units: a systematic review

BACKGROUND

Breastfeeding/breastmilk feeding of infants in neonatal units is vital to the preservation of short- and long-term health, but rates are very low in many neonatal units internationally. The aim of this review was to evaluate the effectiveness of clinical, public health and health promotion interventions that may promote or inhibit breastfeeding/breastmilk feeding for infants admitted to neonatal units.

METHODS

Systematic review with narrative synthesis. Studies were identified from structured searches of 19 electronic databases from inception to February 2008; hand searching of bibliographies; Advisory Group members helped identify additional sources.

INCLUSION CRITERIA

controlled studies of interventions intended to increase breastfeeding/feeding with breastmilk that reported breastmilk feeding outcomes and included infants admitted to neonatal units, their mothers, families and caregivers. Data were extracted and appraised for quality using standard processes. Study selection, data extraction and quality assessment were independently checked. Study heterogeneity prevented meta-analysis.

RESULTS

Forty-eight studies were identified, mainly measuring short-term outcomes of single interventions in stable infants. We report here a sub-set of 21 studies addressing interventions tested in at least one good-quality or more than one moderate-quality study. Effective interventions identified included kangaroo skin-to-skin contact, simultaneous milk expression, peer support in hospital and community, multidisciplinary staff training, and Unicef Baby Friendly accreditation of the associated maternity hospital.

CONCLUSIONS

Breastfeeding/breastmilk feeding is promoted by close, continuing skin-to-skin contact between mother and infant, effective breastmilk expression, peer support in hospital and community, and staff training. Evidence gaps include health outcomes and costs of intervening with less clinically stable infants, and maternal health and well-being. Effects of public health and policy interventions and the organization of neonatal services remain unclear. Infant feeding in neonatal units should be included in public health surveillance and policy development; relevant definitions are proposed.

The devil is in the detail - a multifactorial intervention to reduce blood pressure in co-existing diabetes and chronic kidney disease: a single blind, randomized controlled trial

Background

About 30-60% of individuals are non-adherent to their prescribed medications and this risk increases as the number of prescribed medications increases. This paper outlines the development of a consumer-centred Medicine Self-Management Intervention (MESMI), designed to improve blood pressure control and medication adherence in consumers with diabetes and chronic kidney disease recruited from specialist outpatients' clinics.

Methods

We developed a multifactorial intervention consisting of Self Blood Pressure Monitoring (SBPM), medication review, a twenty-minute interactive Digital Versatile Disc (DVD), and follow-up support telephone calls to help consumers improve their blood pressure control and take their medications as prescribed. The intervention is novel in that it has been developed from analysis of consumer and health professional views, and includes consumer video exemplars in the DVD. The primary outcome measure was a drop of 3-6 mmHg systolic blood pressure at three months after completion of the intervention. Secondary outcome measures included: assessment of medication adherence, medication self-efficacy and general wellbeing. Consumers' adherence to their prescribed medications was measured by manual pill count, self-report of medication adherence, and surrogate biochemical markers of disease control.

Discussion

The management of complex health problems is an increasing component of health care practice, and requires interventions that improve patient outcomes. We describe the preparatory work and baseline data of a single blind, randomized controlled trial involving consumers requiring cross-specialty care with a follow-up period extending to 12 months post-baseline.

Trial Registration

The trial was registered with the Australian and New Zealand Clinical Trials Register (ACTRN12607000044426).

Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis

OBJECTIVES

To evaluate the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or feeding with breastmilk for infants admitted to neonatal units, and to identify an agenda for future research.

DATA SOURCES

Electronic databases were searched (including MEDLINE and MEDLINE In-Process Citations, EMBASE, CINAHL, Maternity and Infant Care, PsycINFO, British Nursing Index and Archive, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Science Citation Index, Pascal, Latin American and Caribbean Health Sciences, MetaRegister of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessment Database, National Research Register) from inception to February 2008. Advisors identified further published or unpublished material.

REVIEW METHODS

All papers fulfilled eligibility criteria covering participants, interventions, study design and outcomes. Results from primary studies were assessed and summarised in a qualitative synthesis for each type of intervention and across types of intervention. To estimate long-term cost utility, a decision tree was developed to synthesise data on enhanced staff contact, breastmilk effectiveness, incidence of necrotising enterocolitis (NEC) and sepsis, resource use, survival and utilities.

RESULTS

Forty-eight studies met the selection criteria for the effectiveness review, of which 65% (31/48) were RCTs, and 17% (8/48) were conducted in the UK. Seven were rated as good quality and 28 as moderate quality. No studies met the selection criteria for the health economics review. There is strong evidence that short periods of kangaroo skin-to-skin contact increased the duration of any breastfeeding for 1 month after discharge [risk ratio (RR) 4.76, 95% confidence interval (CI) 1.19 to 19.10] and for more than 6 weeks (RR 1.95, 95% CI 1.03 to 3.70) among clinically stable infants in industrialised settings. There is strong evidence for the effectiveness of peer support at home (in Manila) for mothers of term, low birthweight infants on any breastfeeding up to 24 weeks (RR 2.18, 95% CI 1.45 to 3.29) and exclusive breastfeeding from birth to 6 months (RR 65.94, 95% CI 4.12 to 1055.70), and for the effectiveness of peer support in hospital and at home for mothers of infants in Special Care Baby Units on providing any breastmilk at 12 weeks [odds ratio (OR) 2.81, 95% CI 1.11 to 7.14; p = 0.01]. There is more limited evidence for the effectiveness of skilled professional support in a US Neonatal Intensive Care Unit on infants receiving any breastmilk at discharge (OR 2.0, 95% CI 1.2 to 3.2, p = 0.004). Multidisciplinary staff training may increase knowledge and can increase initiation rates and duration of breastfeeding, although evidence is limited. Lack of staff training is an important barrier to implementation of effective interventions. Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal units. Limited evidence suggests that cup feeding (versus bottle feeding) may increase breastfeeding at discharge and reduce the frequency of oxygen desaturation. Breastmilk expression using simultaneous pumping with an electric pump has advantages in the first 2 weeks. Pharmaceutical galactagogues have little benefit among mothers who have recently given birth. Our economic analysis found that additional skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Additional support ranged from 0.009 quality-adjusted life-years (QALYs) to 0.251 QALYs more beneficial per infant and ranged from 66 pounds to 586 pounds cheaper per infant across the birthweight subpopulations. Donor milk would become cost-effective given improved mechanisms for its provision.

CONCLUSIONS

Despite the limitations of the evidence base, kangaroo skin-to-skin contact, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital have been shown to be effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. All these point to future research priorities. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone. There is a need for national surveillance of feeding, health and cost outcomes for infants and mothers in neonatal units; to assist this goal, we propose consensus definitions of the initiation and duration of breastfeeding/breastmilk feeding with specific reference to infants admitted to neonatal units and their mothers.

Early N-terminal pro-brain natriuretic peptide measurements predict clinically significant ductus arteriosus in preterm infants

We report a blinded, prospective study of the diagnostic utility of N-terminal pro-brain natriuretic peptide (NTproBNP) measurements for predicting clinically significant patent ductus arteriosus (PDA) and assessing closure.

METHODS

Plasma NTproBNP was measured during the first week in 100 preterm babies (mean gestation 28.8 +/- 2.9 weeks; mean birth weight 1224 +/- 512 g). Echocardiography was performed between days 5 and 7 by operators, blinded to NTproBNP concentration.

RESULTS

NTproBNP peaked on days 2 and 3, declined by day 7. Twenty babies, later treated for PDA, had significantly higher NTproBNP levels throughout. Areas under receiver operating characteristic (ROC) curves were 0.896, 0.897 and 0.931 on days 2, 3 and 7, respectively (p < 0.0001). A concentration > 2850 pmol/L had diagnostic sensitivity of 90% and specificity of 89% (95% CI: 68, 99; likelihood ratio 8.10). Ductal closure was associated with a fall in mean NTproBNP from 3003 to 839 pmol/L (p < 0.001).

CONCLUSION

N-terminal pro B-type brain natriuretic peptide (NTproBNP) concentrations peaked and then declined in the first week but remained higher in preterm babies whose PDA required treatment. NTproBNP on day 3 predicted whether a neonatal physician blinded to results would treat a PDA. Fall in plasma NTproBNP indicated closure.

Adherence to multiple, prescribed medications in diabetic kidney disease: A qualitative study of consumers' and health professionals' perspectives

BACKGROUND

Individuals are adherent to approximately 50% of their prescribed medications, which decreases when multiple, chronic conditions are involved.

OBJECTIVE

To examine factors affecting adherence to multiple prescribed medications for consumers with co-existing diabetes and chronic kidney disease (diabetic kidney disease) from the time of prescription to the time they took their medications.

DESIGN

A descriptive exploratory design was used incorporating in-depth interviews and focus groups.

SETTING

The diabetes and nephrology departments of two metropolitan, public hospitals in Melbourne, Australia.

PARTICIPANTS

A convenience sample of 23 consumers with diabetic kidney disease participated in an in-depth interview. Inclusion criteria involved English-speaking individuals, aged > or =18 years, with co-existing diabetes and chronic kidney disease, and who were mentally competent. Exclusion criteria included impending commencement on dialysis, pregnancy, an aggressive form of cancer, or a mental syndrome that was not stabilised with medication. Sixteen health professionals working in diabetes and nephrology departments in Melbourne, Australia also participated in one of two focus groups.

METHODS

In-depth structured interviews and focus groups were conducted and analysed according to a model of medication adherence.

RESULTS

Consumers were not convinced of the need, effectiveness and safety of all of their medications. Alternatively, health professionals focussed on the importance of consumers taking their medications as prescribed and believed that the risk of medication-related adverse effects was over-rated. Accessing prescribed medications and difficulties surrounding continuity of care contributed to consumers' unintentional medication non-adherence. In particular, it was hard for consumers to persist taking their ongoing medication prescriptions. Healthcare system inadequacies were highlighted, which affected relationships between consumers with diabetic kidney disease and health professionals.

CONCLUSIONS

Acknowledging the barriers as perceived by consumers with diabetic kidney disease can facilitate effective communication and partnerships with health professionals necessary for medication adherence and medication safety.

The National Open Disclosure Pilot: evaluation of a policy implementation initiative

OBJECTIVE

To determine which aspects of open disclosure "work" for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot.

DESIGN, SETTING AND PARTICIPANTS

Qualitative analysis of semi-structured and open-ended interviews conducted between March and October 2007 with 131 clinical staff and 23 patients and family members who had participated in one or more open disclosure meetings. 21 of 40 pilot hospital sites, in New South Wales, South Australia, Victoria and Queensland, were included in the evaluation. Participating health care staff comprised 49 doctors, 20 nurses, and 62 managerial and support staff. In-depth qualitative data analysis involved mapping of discursive themes and subthemes across the interview transcripts.

RESULTS

Interviewees broadly supported open disclosure; they expressed uncertainty about its deployment and consequences, and made detailed suggestions of ways to optimise the experience, including careful pre-planning, participation by senior medical staff, and attentiveness to consumers' experience of the adverse event.

CONCLUSION

Despite some uncertainties, the national evaluation indicates strong support for open disclosure from both health care staff and consumers, as well as a need to resource this new practice.

Vitamin D in pregnancy: an old problem still to be solved?

Perspective on the paper by Dijkstra et al (see page 750 )

Young driver risk factors: successful and unsuccessful approaches for dealing with them and an agenda for the future

The extent to which various interventions to deal with the young driver crash problem have worked are discussed, and promising interventions that should be tried are identified. Traditional forms of driver licensing and driver education have not worked. Graduated licensing reduces the problem and existing laws need to be strengthened. Programs involving parents and police have shown some potential to increase compliance with graduated licensing restrictions. Insurer discount programs also have potential. In other public health areas, comprehensive programs have worked better than those based on single components. There are continuing efforts to develop new driver education and training programs and methods of delivery that can combine with graduated licensing and contribute to reductions in the young driver problem. The most promising intervention strategy is likely to be a coordinated community based program in states with strong graduated licensing laws as a foundation, involving modern education and training techniques, insurance discount programs, and well publicized enforcement and education programs featuring parents and police in combination, with as much input and participation as possible from the target group of young drivers.

Neonatal hypoglycaemia: clinical and legal aspects

Transiently low blood glucose levels are common in the neonatal period and may be considered a normal feature of adaptation to extrauterine life. There is no evidence that this causes brain injury in the absence of concurrent clinical manifestations. Conversely, persistent and severe hypoglycaemia may be associated with other underlying pathologies which themselves predispose to brain injury. Attribution of brain injury therefore requires demonstration of both 'significant' hypoglycaemia and a characteristic resulting pattern of brain injury. The prevention of hypoglycaemic brain injury requires early detection in infants considered 'at risk' and appropriate intervention. No single concentration of plasma glucose can be associated universally with either the appearance of clinical signs or causation of cerebral injury. For this reason we suggest that treatment be based upon 'operational thresholds' and guided by clinical assessment, not by the plasma glucose concentration alone. For example, the infant displaying neurological signs requires more urgent elevation of blood glucose concentration than the 'asymptomatic' one, regardless of the absolute plasma glucose value.

Temporal factors in motor vehicle crash deaths

OBJECTIVE

To summarize fatal motor vehicle crash deaths in the United States by time of day, day of week, month, and season, and to determine why some days of the year tend to experience a relatively high number of deaths.

METHOD

Crash deaths were identified and categorized using the Fatality Analysis Reporting System. Days of the year with relatively high crash deaths were compared to the two days that occurred exactly one week before and one week after.

RESULTS

On average, motor vehicle crashes in the United States result in more than 100 deaths per day, but there is much day-to-day variability. During 1986-2002 the single day fatality count ranged from a low of 45 to a high of 252. Summer and fall months experience more crash deaths than winter and spring, largely due to increased vehicle travel. July 4 (Independence Day) has more crash deaths on average than any other day of the year, with a relatively high number of deaths involving alcohol. January 1 (New Year's Day) has more pedestrian crash deaths on average, plus it has the fifth largest number of deaths per day overall, also due to alcohol impairment. On other days the high numbers of deaths are likely due to increases in holiday or recreational travel.

CONCLUSION

Every day of the year results in many crash deaths, but certain days stand out as particularly risky. The temporal and geographic spread of crash deaths, as well as the view of driving as a routine task, inures the public to this continuing problem. Innovative strategies are needed both to raise awareness and to work toward a solution.

Lymphoedema: an underestimated health problem

BACKGROUND

Lymphoedema/chronic oedema is an important cause of morbidity in the population, but little is known of its epidemiology and impact on patients or health services.

AIM

To determine the magnitude of the problem of chronic oedema in the community, and the likely impact of oedema on use of health resources, employment and patient's quality of life.

DESIGN

Questionnaire-based survey.

METHODS

Health professionals from dedicated lymphoedema services, specific out-patient clinics, hospital wards and community services (GP clinics and district nurses) were contacted to provide information on patients from within South West London Community Trust. A subset of the identified patients was interviewed.

RESULTS

Within the catchment area, 823 patients had chronic oedema (crude prevalence 1.33/1000). Prevalence increased with age (5.4/1000 in those aged > 65 years), and was higher in women (2.15 vs. 0.47/1000). Only 529 (64%) were receiving treatment, despite two specialist lymphoedema clinics within the catchment area. Of 228 patients interviewed, 78% had oedema lasting > 1 year. Over the previous year, 64/218 (29%) had had an acute infection in the affected area, 17/64 (27%) being admitted for intravenous antibiotics. Mean length of stay for this condition was 12 days, estimated mean cost pound 2300. Oedema caused time off work in > 80%, and affected employment status in 9%. Quality of life was below normal, with 50% experiencing pain or discomfort from their oedema.

DISCUSSION

Chronic oedema is a common problem in the community with at least 100 000 patients suffering in the UK alone, a problem poorly recognized by health professionals. Lymphoedema arising for reasons other than cancer treatment is much more prevalent than generally perceived, yet resources for treatment are mainly cancer-based, leading to inequalities of care.

Seatbelt use by high school students

OBJECTIVE

To determine seatbelt use of teenage drivers arriving at high schools in the morning and at evening football games compared with belt use of adults driving teenage passengers to these events, and teenage passenger belt use depending on whether they were being driven by another teenager or an adult.

METHODS

Unobtrusive observations of belt use were made at 12 high schools in Connecticut and Massachusetts.

RESULTS

Among males, teenage drivers had lower belt use than adults; differences between female teenage and female adult drivers were slight. Teenage passengers had lower belt use in vehicles driven by other teenagers than in cars driven by adults, but more than 40% of teenage passengers in vehicles driven by adults, presumed in most cases to be the teenager's parent, were not belted. Teenage passenger belt use was lower than teenage driver use regardless of gender. These differences were found both at morning arrivals and at football games, but teenage belt use was not much different in these two settings. Teenage passengers were belted more often if drivers were belted, whether the driver was another teenager or an adult, but a third of male passengers and 25%-30% of female passengers were unbelted even when drivers were belted.

CONCLUSION

Teenagers have high crash risk but low belt use, which adds to their injury problem. Avenues to address this include strong belt use laws and their enforcement, building belt use requirements into graduated licensing systems, keeping young beginners out of high risk driving situations, and finding ways to influence parents and other adults to ensure that their teenage passengers use seatbelts.

A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema

This paper describes a randomized controlled crossover study examining the effects of manual lymphatic drainage (MLD) in 31 women with breast cancer-related lymphoedema. MLD is a type of massage used in combination with skin care, support/compression therapy and exercise in the management of lymphoedema. A modified version of MLD, referred to as simple lymphatic drainage (SLD), is commonly taught as a self-help measure. There has been limited research into the efficacy of MLD and SLD. The study reported here explores the effects of MLD and SLD on a range of outcome measures. The findings demonstrate that MLD significantly reduces excess limb volume (difference, d=71, 95% CI=16-126, P=0.013) and reduced dermal thickness in the upper arm (d=0.15, 95% CI=0.12-0.29, P =0.03). Quality of life, in terms of emotional function (d=7.2, 95% CI=2.3-12.1, P=0.006), dyspnoea (d=-4.6, 95% CI=-9.1 to -0.15, P=0.04) and sleep disturbance (d =-9.2, 95% CI=-17.4 to -1.0, P=0.03), and a number of altered sensations, such as pain and heaviness, were also significantly improved by MLD. The study provides evidence to support the use of MLD in women with breast cancer-related lymphoedema. The limitations of the study are outlined and future areas for study are highlighted.

Effectiveness of Ford's belt reminder system in increasing seat belt use

OBJECTIVES

The study investigated the effectiveness in increasing seat belt use of Ford's belt reminder system, a supplementary system that provides intermittent flashing lights and chimes for five minutes if drivers are not belted.

METHODS

Seat belt use of drivers in relatively new cars with and without the reminder system was unobtrusively observed as vehicles were brought to dealerships for service.

RESULTS

Overall use rates were estimated at 71% for drivers in vehicles without the reminder system and 76% for drivers in vehicles with belt reminders (p<0.01).

CONCLUSIONS

Seat belt use is relatively low in the United States. The present study showed that vehicle based reminder systems can be at least modestly effective in increasing belt use, which may encourage further development of such systems.

Drinking histories of fatally injured drivers

CONTEXT

About 30% of drivers killed in crashes have high blood alcohol concentrations (BACs) of 0.10+ g/dl. There is a question about whether these drivers primarily are problem drinkers who chronically drink and drive-the so-called hard core drinking drivers.

OBJECTIVE

To investigate drinking histories of fatally injured drivers in relation to their BACs.

DESIGN AND PARTICIPANTS

Retrospective cohort study of 818 fatally injured drivers who were included in the 1993 National Mortality Followback Survey (a national sample of US deaths in which next of kin were interviewed) and whose BACs were recorded by the Fatality Analysis Reporting System, a census of US traffic deaths.

MAIN OUTCOME MEASURE

Problem drinking indicators.

RESULTS

At least one indicator of potential problem drinking, primarily heavy drinking, was reported for 68% of drivers with very high BACs (0.15+ g/dl), 41% with BACs of 0.10-0.14 g/dl, 32% with BACs of 0.01-0.09 g/dl, and 7% with zero BACs. Spouses provided more credible responses than other relatives: they were more likely to report at least occasional drinking and driving among deceased drivers with high BACs. For the most direct signs of problem drinking (described as a problem drinker during the last month of life or frequently driving after having five or more drinks), spousal reports suggested the prevalence of problem drinking among drivers with very high BACs was 22% (having both indicators), 32% (frequently driving after having five or more drinks), 44% (described as problem drinker), or 57% (having either indicator).

CONCLUSIONS

Drivers with BACs of 0.10+ g/dl were far more likely than sober drivers to be described as having markers of problem drinking. However, many did not have indicators suggestive of problem drinking. In addition to programs focused on repeat offenders or problem drinkers, countermeasures such as sobriety checkpoints that target a broader spectrum of drinking drivers are appropriate.

Rationale for graduated licensing and the risks it should address

The increased crash risk of young, beginning drivers has long been cause for concern. Graduated licensing systems, which seek to phase in driving experience gradually over time, have recently been adopted by many states in an effort to reduce these risks. In an attempt to define the basic rationale for graduated licensing, relevant research evidence that describes the conditions under which risk is known to be increased for young drivers was reviewed. Potential changes in licensing laws that best address these known risk factors are described. It was found that certain situations contribute to even greater crash risk, most notably nighttime driving and driving with passengers in the peer group. The underlying premise for graduated licensing is that while crash risk of young drivers is heightened under all situations, some situations are more or less risky than others. If experience can be gained initially under lower risk conditions, both in the learning stage and when first licensed, crash risk will be reduced.

Plasma brain natriuretic peptide as a predictor of haemodynamically significant patent ductus arteriosus in preterm infants

Patent ductus arteriosus (PDA) is an important cause of morbidity in extremely preterm infants. As increased plasma brain natriuretic peptide (BNP) is a common feature of adult cardiac disease, we investigated the value of plasma BNP concentration as a predictor of haemodynamically significant PDA in very preterm infants. We studied 18 preterm infants (12 male) of median gestational age 30 weeks (range 24-34), median birth weight 1.46 kg (0.54-2.13) and 11 healthy term controls. Plasma BNP levels were measured by double-antibody radioimmunoassay on days 3, 5 and 7 of life, and an echocardiogram was performed on day 7. Six infants of median gestation 26 weeks (26-30), median birth weight 0.92 kg (0.54-1.04) had PDA proven by echocardiography on day 7. BNP concentrations (pg/ml) on day 3 were significantly higher in these infants than in the remaining twelve [median 2012 (786-2759) versus 42 (7-704), P<0.001]. In four infants PDA was treated successfully (one surgically, three with non-steroidal anti-inflammatory drugs). Two had haemodynamically insignificant closing ducts. In these infants with therapeutic or spontaneous resolution of a PDA, plasma BNP fell to normal values [median after treatment 9 pg/ml (8-27)]. Early measurement of plasma BNP in the first few days of life is a useful method for predicting those preterm infants who may require intervention for PDA.

Older driver involvements in police reported crashes and fatal crashes: trends and projections

OBJECTIVES

Older drivers have become a larger part of the driving population and will continue to do so as the baby boomers reach retirement age. The purpose of this study was to identify the potential effects of this population increase on highway safety.

METHODS

Driver involvement rates for all police reported crashes were calculated per capita, per licensed driver, and per vehicle-mile of travel for 1990 and 1995. Also, driver involvement rates for fatal crashes were calculated for 1983, 1990, and 1995. Based on current crash rates per licensed driver and estimates of the future number of licensed drivers, projections of crashes involving drivers aged 65 and older were made for years 2010, 2020, and 2030.

RESULTS

Driver crash involvement rates per capita decreased with age, but fatal involvement rates per capita increased starting at age 70. The same pattern existed for involvement rates per licensed driver. For both all crashes and fatal crashes, involvement rates per mile driven increased appreciably at age 70. Using projections of population growth, it was estimated that for all ages there will be a 34% increase in the number of drivers involved in police reported crashes and a 39% increase in the number involved in fatal crashes between 1999 and 2030. In contrast, among older drivers, police reported crash involvements are expected to increase by 178% and fatal involvements may increase by 155% by 2030. Drivers aged 65 and older will account for more than half of the total increase in fatal crashes and about 40% of the expected increase in all crash involvements; they are expected to account for as much as 25% of total driver fatalities in 2030, compared with 14% presently.

CONCLUSIONS

By most measures, older drivers are at less risk of being involved in police reported crashes but at higher risk of being in fatal crashes. Although any projections of future crash counts have inherent uncertainty, there is strong evidence that older drivers will make up a substantially larger proportion of drivers involved in fatal crashes by 2030 because of future increases in the proportion of the population aged 65 and older, and trends toward increased licensure rates and higher annual mileage among older persons. Countermeasures to reduce the anticipated death toll among older drivers should address the increased susceptibility to injury of older vehicle occupants in crashes.

Growth reference charts for use in the United Kingdom

Since the introduction of new growth charts in the mid 1990s, there has been confusion about which charts should be used, with many districts using more than one version. Because of this uncertainty, an expert working party, the Growth Reference Review Group, was convened by the Royal College of Paediatrics and Child Health to provide guidance on the validity and comparability of the different charts currently in use. This paper describes the technical background to the construction and evaluation of growth charts and outlines the group's findings on the validity of each growth reference in relation to contemporary British children. The group concluded that for most clinical purposes the UK90 reference is superior and for many measures is the only usable reference that can be recommended, while the original Tanner-Whitehouse and the Gairdner-Pearson charts are no longer reliable for use at any age. After the age of 2 the revised Buckler-Tanner references are still suitable for assessing height. There are presently no reliable head circumference reference charts for use beyond infancy. The group propose that apart from refinements of chart design and layout, the new UK90 reference should now be "frozen", with any future revisions only undertaken after careful planning and widespread consultation.

A simple method for identifying and correcting crash problems on urban arterial streets

Urban arterials by their nature carry heavy traffic volumes and generate large numbers of motor vehicle crashes. The present study involved review of police crash reports to identify precrash events and driver actions for a sample of crashes on urban arterials and describes a method for reducing such crashes based on analyses of collision patterns and identification of locations with excessive numbers of crashes of a particular type. Police-reported crash data were obtained for three urban arterials in the Washington, DC metropolitan area. A total of 2,013 crash reports were analyzed. Seven crash types accounted for nearly 90% of these reports. On each arterial studied, several locations with excessive numbers of crashes of a particular type were identified, and corresponding engineering countermeasures were recommended. Differences between the approach employed in this study and traditional blackspot analyses are discussed.

Molecular tricorns: self-assembly of trinuclear palladium(II) complexes

Cyclometalation of the ligand 1,3-bis(1-alkylbenzimidazol-2-yl)benzene (1) with palladium carboxylates leads to a trimeric complex [Pd(3)(ligand)(3)(carboxylate)(3)] (3). Studies in solution show that the trinuclear core is stable but that the carboxylates are labile, undergoing intra- and intermolecular exchange on an NMR time scale. The structural analogue of 1, 2,6-bis(1-alkylbenzimidazol-2-yl)pyridine (4), gives only the mononuclear species [Pd(4)(carboxylate)(2)], characterized by X-ray diffraction. This complex forms a trimer if one carboxylate is labilized by the addition of strong acid; the resulting trinuclear species is readily cleaved by nucleophiles but can include weakly basic anions within its cavity.

Relationship of parent driving records to the driving records of their children

Many studies have shown that young driver crash rates can be influenced by such factors as lifestyle characteristics and licensing systems. However, the influence of parents on their teenage children's crash and violation rates has not received much attention. The present study used data from the North Carolina driver history file to match the crash and violation records of young drivers between the ages of 18 and 21 with those of their parents. Results indicate that children's driving records in the first few years of licensure are related to the driving records of their parents. Children whose parents had three or more crashes on their record were 22% more likely to have had at least one crash compared with children whose parents had no crashes. Likewise, children whose parents had three or more violations were 38% more likely to have had a violation compared with children whose parents had none. Logistic regression models showed that these relationships held when controlling for household type and child gender.

Variations in teenage activities with and without a driver's license

High school students were surveyed every 6 months from their freshman through senior years concerning licensing, driving, and transportation to and from their various activities. Students in Delaware (learner's permit can be issued at age 15 years, 10 months; driver's license at age 16) were compared with students in Connecticut and New York (permit at age 16; license at age 16) and in New Jersey (license at age 17). During the junior year, most Delaware students, some New York and Connecticut students, and few New Jersey students were licensed. However, even during the junior year, students in the respective states did not differ significantly with respect to time spent at activities such as a paying job, homework, watching television, dating, parties, being with friends, talking on the phone, or participating in sports or school activities. Graduated licensing systems can delay full-privilege teenage licensure and reduce teenage crash rates. These systems also can increase the number of times parents and others must drive. However, the present study's results indicate that licensing delays of as much as 1 year have minimal effects on the nondriving activities of high school students.

Measurement of carbon dioxide production in very low birth weight babies

BACKGROUND

CO2 production is most commonly measured by using indirect calorimetry to quantify elimination of CO(2) in breath (VCO2). An alternative is to measure the rate at which CO2 appears in the body pool (RaCO2) by infusing a (13)C labelled bicarbonate tracer. VCO2 and RaCO2 generally differ but are related by c, a factor that adjusts for the incomplete recovery of infused tracer in the breath. The literature relating to human studies cites a wide range of values for c but the only neonatal study to determine c empirically estimated a mean value of 0.77.

AIM

To estimate fractional recovery rate, c, in very low birthweight babies, and assess the feasibility of using the isotopic technique to measure CO2 production during mechanical ventilation.

METHOD

Eleven spontaneously breathing, continuously fed, very low birthweight infants (median birth weight 1060 g, median gestational age 29 weeks) were studied.

RESULTS

Mean (SD) VCO2 was 9.0 (2.0) ml/min (standard temperature and pressure dry, STPD) and mean (SD) RaCO2 was 9.6 (2.1) ml/min (STPD). The mean (SD) value of c was estimated as 0.95 (0.13). The 95% confidence intervals of the mean were 0.87-1.03.

CONCLUSIONS

The results emphasise the importance of measuring c for a given study population rather than assuming a value based on adult studies. The close approximation of RaCO2 and VCO2 in this group of babies implies that the labelled bicarbonate infusion technique could be used to measure simply CO2 production during mechanical ventilation.

Effect of Florida's graduated licensing program on the crash rate of teenage drivers

On 1 July 1996, Florida instituted a graduated licensing program for drivers younger than age 18. For the first 3 months, holders of learner's licenses are not allowed to drive at all between 19:00 and 06:00 h; thereafter, they may drive until 22:00 h. Learner's licenses must be held for 6 months prior to eligibility for the intermediate license. Sixteen-year-old intermediate license holders are not permitted to drive unsupervised from 23:00 to 06:00 h, 17 year-olds from 01:00 to 06:00 h. All drivers younger than 18 have strict limits on the number of traffic violations they can accumulate and, effective 1 January 1997, all drivers younger than 21 are subject to a zero tolerance law for drinking and driving. Florida crash data for 1995-1997 were obtained and compared with similar data from Alabama, a state that borders Florida but does not have graduated licensing. For 15, 16, and 17 year-olds combined, there was a 9% reduction in the fatal and injury crash involvement rate in Florida during 1997, the first full year of graduated licensing, compared with 1995. On a percentage basis, crashes declined most among 15 year-olds, followed by 16 year-olds and then 17 year-olds. Reductions were not seen among Alabama teenagers nor among 18 year-olds in Florida.

Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds

The definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology. In this article, some of the reasons for these contentions are discussed. Pragmatic recommendations for operational thresholds, ie, blood glucose levels at which clinical interventions should be considered, are offered in light of current knowledge to aid health care providers in neonatal medicine. Future areas of research to resolve some of these issues are also presented.

Neck pain and head restraint position relative to the driver's head in rear-end collisions

This two-year investigation was designed to estimate the incidence of driver neck pain in rear-struck vehicles involved in two-vehicle collisions and to determine the relationship between neck pain and specific vehicle, human, and environmental factors. Neck pain percentages were significantly higher for female (45%) than for male (28%) drivers. For female and male drivers, neck pain likelihood increased as head restraint height decreased below the head's center of gravity, although this effect was significant only for females. Head restraint backset, the horizontal distance measured from the back of the driver's head to the front of the head restraint, was not found to be related to neck pain for female drivers. Backset trends for male drivers could not be evaluated because few male drivers had head restraints that were high enough for backset to be relevant. Reported neck pain decreased for older drivers (females only), drivers in less severe crashes, and drivers in heavier cars (females only); all head restraint analyses were adjusted for these characteristics. Women, and most likely men, in the United States would benefit greatly from international harmonization to European head restraint standards. Until then, both women and men should be encouraged to adjust their adjustable head restraints, if possible, behind their heads' centers of gravity and to sit with the backs of their heads as close as possible to their head restraints.

Child seating position and restraint use in three states

OBJECTIVE

Because of risks from deploying airbags to children in front seats, extensive publicity has been aimed at getting them restrained and in rear seats. The objective of this study was to assess restraint use and seating positions among children in vehicles with and without airbags.

METHOD

Surveys were conducted in cities in Michigan, North Carolina, and Texas 1998. Restraint use and seating position were noted for all children, as well as their estimated age, driver belt use, airbag presence, and vehicle license plate number.

RESULTS

Fewer children were observed in the front seats of vehicles with passenger airbags (24%) than in vehicles without them (36%). Most of the children seated in front were ages 7-12 (44%-61%), followed by 3-6 year olds (29%-35%). Very few children ages 0-2 were seated in front (5%-12%). The overwhelming majority of children ages 0-2 were restrained. However, children ages 3-6 seated in the front were least likely to be restrained and most likely to be improperly restrained. Restraint use was higher when the driver was belted, but about 30% of 3-6 year olds were unrestrained even with a belted driver.

CONCLUSIONS

Efforts should continue to educate parents about the importance of correct restraint use and rear seating for children, particularly once children move from child safety seats into adult belts. Efforts also should be made to enforce the seat belt laws that exist in every state.

Area income as a predictor of preventable hospitalizations in the Harris County Hospital District, Houston

This study assesses whether geographical area income based on census data is a good predictor of preventable (or ambulatory care-sensitive) hospitalizations in a large public hospital system in Texas, and how area income correlates with the socioeconomic status reported by patients. Documenting a correspondence between area and individual-level income, as well as meaningful variation in rates of avoidable hospitalizations across subgroups and areas with varying concentrations of low-income persons, points to the validity and utility of this approach for monitoring how well public hospital systems in Texas address the needs of those they most directly serve. Area income may not fully reflect the disproportionately lower socioeconomic status of patients seen in the public hospital system. Nonetheless, living in lower-income zip codes was associated with higher preventable hospitalization rates for the predominantly low-income population served by the public hospital system. A tenfold difference found in the adjusted rates of hospitalizations for preventable conditions compared with control (or marker) conditions among persons living in low-income areas signals the likelihood of substantial unmet needs in this population. Small-area analysis and related comparisons of rates of preventable hospitalizations in high- and low-income areas provide useful indicators for monitoring and assessing the performance of public hospital systems in Texas.