Risk factors associated with challenging behaviour in people with profound intellectual and multiple disabilities

BACKGROUND

Several factors that correlate with the onset or continuation of challenging behaviour are mentioned in research. These are factors related to persons with ID, but also to direct support professionals and the context. Although many of these factors seem to affect the onset or continuation of challenging behaviour in people with ID in general, results are often inconclusive and have little focus on people with profound intellectual and multiple disabilities (PIMD). The present study aimed to assess the extent to which known factors related to challenging behaviour are also applicable to a group of 198 people with PIMD.

METHOD

To determine which factors were associated with challenging behaviour, univariate analyses on associations between known risk factors and challenging behaviour were conducted. The associated factors were then subject to a regression analysis to determine the extent to which they explain the prevalence of challenging behaviour and can thus be seen as factors associated with challenging behaviour.

RESULTS

The results show that, in particular, factors concerning the personal characteristics of people with PIMD, such as sleeping problems and auditory problems, were related to the variance in mean frequency of challenging behaviour. Only one factor related to the direct support professionals was found: when these professionals had been offered training on the subject of challenging behaviour in people with intellectual disabilities in general, they identified significantly more withdrawn behaviour. We found no contextual factors related to challenging behaviour.

CONCLUSION

These findings are generally consistent with findings reported in other studies, especially concerning the personal characteristics of people with PIMD. Further research should focus on the effects of providing safe auditory environments and appropriate sleep schedules for people with PIMD on the occurrence of challenging behaviour.

Phonetic and phonemic acquisition: normative data in English and Dutch speech sound development

OBJECTIVE

Comparison of normative data in English and Dutch speech sound development in young children. Research questions were: Which normative data are present concerning speech sound development in children between two and six years of age? In which way are the speech sounds examined? What are the differences and similarities between the development of speech sounds in different languages?

METHODS

A literature study on the subject was performed to be able to answer the research questions.

RESULTS

The presented normative English data showed that all vowels are present at three years of age, and most consonants (singletons) already at four years of age, except for/ʃ, ɹ, θ, ð/. Consonant clusters develop between 4.5 and 5.5 years of age. The phonological error patterns gliding can be present until six years of age. According to information regarding the Dutch speech sound system, the same ages are found for vowels and single consonants. The age of acquisition of most consonant clusters is present at about six years of age, but the development goes on until ten years of age.

CONCLUSION

The data from the development of the English and Dutch speech sound system show many similar tendencies. Vowels are mastered by the age of three, most consonants by the age of four and most consonant clusters between 5 and 6-8 years of age. Perhaps, there is a universal trend in speech sound development like there is in language development.

Behavioural problems in young children with language problems

OBJECTIVE

Analysis of behavioural problems in young children with language problems.

MATERIALS AND METHODS

From 38 children diagnosed with a language problem, the opinion of the parents about the behaviour of their child, scored by the Child Behaviour Checklist 1.5-5 was compared with the behavioural problems in the Dutch population with the Chi-square test. T-tests and Mc Nemar tests were used to compare the opinion of the fathers about the behavioural problems with the opinion of the mothers and to compare the scores on internalizing problems with scores on externalizing problems. Plots display the measurement of the mean behavioural problems of the parents against the discrepancy between the parents and of the total behavioural problems against the discrepancy between internalizing and externalizing problems. The relation between the behavioural problems, the language score and the non-verbal intelligence score was also compared and is presented in a bar chart.

RESULTS

All children had an inadequate language production (GDS). Twenty-seven children had an adequate and 11 children had an inadequate Language Comprehension Quotient (LCQ). Twenty-eight children had an adequate and 10 children had an inadequate non-verbal IQ (SON-IQ). In the clinical population mothers report more internalizing behavioural problems than in Dutch peers. The fathers also experience differences, but these are not significant. There is agreement between the parents in how they experience problems on the internalizing, externalizing and total problem scale. And there are no significant differences between the internalizing and externalizing problem scales, between boys and girls, and in behavioural problems in children with both adequate LCQ and SON-IQ and with inadequate LCQ and/or SON-IQ.

CONCLUSION

Compared to their peers in the Dutch population, young children with language problems show more internalizing problems according to their mothers. The fathers also experience differences, but these are not significant. Fathers and mothers agree on the behaviour analysis of their child and there are no differences between the occurrences of internalizing or externalizing problems and between boys and girls. There is also no relation between the behavioural problems and the severity of the language problem or the level of non-verbal functioning.

Self-assessed tactical skills in elite youth soccer players: a longitudinal study

Self-assessed tactical skills were investigated among 191 youth soccer players from ages 14 through 18 playing in different field positions. On a yearly basis, all players completed the Tactical Skills Inventory for Sports with scales for attacking and defensive situations and for declarative and procedural knowledge. A model to assess whether tactical skills change over time in each field position was developed using multilevel analysis. The models indicated that defenders and midfielders did not improve their tactical skills, whereas attackers increased their tactical skills from ages 14 to 18 years. The representing part of tactical skills for defenders is Acting in Changing Situations, for midfielders Positioning and Deciding, whereas Knowing About Ball Actions was the qualifying factor for attackers. Possible explanations for these differences in tactical skills among elite youth soccer players are the selection procedures at a younger age and task-specific experiences.

Problems in speech sound production in young children. An inventory study of the opinions of speech therapists

OBJECTIVE

Analysis of examination procedure and diagnosis of articulation problems by speech therapists.

STUDY DESIGN

Survey study.

MATERIALS AND METHODS

Eighty-five Dutch speech therapists (23% response), working in private practises or involved in language screening procedures in Youth Health Care, were questioned regarding the incidence of articulation problems in their practices, the manner of examination, the normative data used, and the importance attached to identifying articulation problems.

RESULTS

According to the speech therapists, articulation problems are present in the majority of children (90%) in their practices. In children between 2 and 5 years of age, 45%; in children between 5 and 8 years of age, 36%; above age 8, about 14% of the children still have articulation problems. Despite their opinion that articulation problems often form a separate aspect of language development, all respondents indicated that they always investigate the speech sound development as part of a total speech and language examination. Frequently, more than one instrument is used. However, none of these instruments are standardised. The speech therapists prefer to examine the children at about 4 years of age, despite their opinion that the speech sounds develop until about 6 years of age. For them, this raises the problem to distinguish between articulation in development and articulation problems. They have the opinion that early treatment is important because of assumed relations with social-emotional development and reading and writing abilities later on.

CONCLUSION

The speech therapists taking part in this study have a good view of the speech sound development of young children. However, due to their concern about communication, social-emotional development, and reading and writing abilities later on, they prefer to identify and treat articulation problems at an early age. More detailed research into the variations in speech sound development, in relation to language development, is needed in order to arrive at effective normative data.

Effect of different treatments in young children with language problems

OBJECTIVE

Analysis of the relationship between treatment and improvement on language scores in children with language problems.

DESIGN

Observational longitudinal study.

MATERIALS AND METHODS

123 children between 2 and 5 years of age, diagnosed as having a language problem were followed for 1 year. By means of monthly questionnaires, the form of intervention received was recorded. Language abilities were measured at baseline and after 1 year. Mixed model analysis was used to determine the relationship between improvement and language scores.

RESULTS

During the year 119 parents returned the monthly questionnaires and four treatment groups were subsequently able to be categorized: language treatment (n=21, 18%), surgical hearing improvement (n=16, 13%), language treatment and surgical hearing improvement (n=42, 35%) and a three-combination group (language treatment, surgical hearing improvement and developmental guidance, n=40, 34%). For the four treatment groups there were no significant differences at baseline for the Language Comprehension Quotient (LCQ) (p=0.07) and Sentence Development Quotient (SDQ) (p=0.09). In all treatment groups the mean Sentence Development Quotient improved significantly (p=0.001). The mean Language Comprehension Quotient did not improve in the surgical hearing improvement group (p=0.42), but improved significantly in the language treatment group, in the language treatment and surgical hearing improvement group and in the three-combination group (p=0.002, 0.040, 0.001). From all included children 38 children (32%) moved from an inadequate to an adequate language score.

CONCLUSION

All distinguished forms of treatment were effective. However, only for a proportion of the children this meant a clinical relevant improvement. For the improvement of language comprehension targeted language therapy seems essential, as children without this (children receiving surgical hearing impairment) did not improve their LCQ.

Cardiovascular and eye activity measures as indices for momentary changes in mental effort during simulated flight

This study examines effects of momentary changes in mental effort on cardiovascular and eye activity measures. A total of 19 male pilots performed an instrument flight task. Task load was manipulated by having the pilots perform flight manoeuvres of varying complexity. Multilevel analyses demonstrated clear effects of momentary changes in mental effort on both the cardiovascular and the eye activity measures. An increase in task load resulted in an increase of heart rate and a decrease in heart rate variability, mean dwell time and fixation duration. Heart rate differentiated between resting period and task execution. Heart rate variability from short data segments provided more insight in intermediate levels of mental effort. The eye activity measures were sensitive to intermediate levels of mental effort as well. Attitude changes resulted in an increase of mean dwell time and mean fixation duration. Task analysis is required to use eye measures as valid indices of mental effort. Having indications of the effects of changing mental demands during daily work of operators is of great importance nowadays. This paper presents an approach to estimate such effects on the basis of heart rate and eye activity measures. In particular, the use of averaged short-term heart rate variability measures is a relatively new aspect.

Assessment of the clinical relevance of quantitative sensory testing with Von Frey monofilaments in patients with allodynia and neuropathic pain. A pilot study

BACKGROUND

Allodynia is a common and disabling symptom in many patients with neuropathic pain. Whereas quantification of pain mostly depends on subjective pain reports, allodynia can also be measured objectively with quantitative sensory testing. In this pilot study, we investigated the clinical relevance of quantitative sensory testing with Von Frey monofilaments in patients with allodynia as a consequence of a neuropathic pain syndrome, by means of correlating subjective pain scores with pain thresholds obtained with quantitative sensory testing.

METHODS

During a 4-week trial, we administered a cannabis extract to 17 patients with allodynia. We quantified the severity of the allodynia with Von Frey monofilaments before, during and after the patients finished the trial. We also asked the patients to rate their pain on a numeric rating scale at these three moments.

RESULTS

We found that most of the effect of the cannabis occurred in the last 2 weeks of the trial. In this phase, we observed that the pain thresholds, as measured with Von Frey monofilaments, were inversely correlated with a decrease of the perceived pain intensity.

CONCLUSION

These preliminary findings indicate clinical relevance of quantitative sensory testing with Von Frey monofilaments in the quantification of allodynia in patients with neuropathic pain, although confirmation of our data is still required in further studies to position this method of quantitative sensory testing as a valuable tool, for example, in the evaluation of therapeutic interventions for neuropathic pain.

Children with language problems in a speech and hearing clinic: background variables and extent of language problems

OBJECTIVE

Analysis of a clinical population referred for language analysis in terms of background variables and extent of language problems.

DESIGN

Descriptive study.

MATERIALS AND METHODS

Children referred to a speech and hearing clinic because of assumed language problems were analyzed with standardized tests for language comprehension (Dutch version of the Reynell Developmental Comprehension Scale) and language production (Schlichting test for sentence development). A language problem was defined when the language quotient score differed 1.3S.D. from the mean (quotient scores< or =80). Furthermore, potential risk factors for language problems were compiled (gender, prematurity, birth weight, family composition, familial aggregation, parental education and daycare/home care).

RESULTS

Two hundred forty children, aged between 2 and 5 years of age were included in the study. A reliable language comprehension quotient (LCQ) was obtained in 204 children (85%) and a reliable sentence development quotient (SDQ) in 206 children (85%). In 35% of the children who were assumed to have language problems, adequate language development was found. The children with language problems differed from the children without language problems with regard to language problems in the family (more family aggregation). Also the former more frequently had parents with a low level of education and more often did not attend daycare. The total referred group differed from the Dutch population with regard to gender (more boys), more instances of low birth weight, more parents with middle and high educational level, more two-parent households, fewer siblings, and more frequent attendance at daycare.

CONCLUSION

Parents with a low level of education more frequently have children with language problems. However, parents with a middle and high level of education are more often concerned about the language development of their child. As a consequence, the overestimation of language problems is a real issue in clinical practice. Normal variations in language development often are not considered. The analysis of compiled background variables indicates that language problems are genetically influenced (gender and family aggregation). Language input also is of importance (interactions with a language-competent parent or caregiver and peers): children with language problems less often attended daycare.

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Ductal carcinoma in situ presenting as microcalcifications: the effect of stereotactic large-core needle biopsy on surgical therapy

The aim of this investigation was to study the efficacy of surgical therapy in patients with non-palpable ductal carcinoma in situ (DCIS) presenting as microcalcifications diagnosed by means of stereotactic large-core needle biopsy (SCNB). This is a retrospective study with a historical control group within a 12-year period. Two groups of consecutive patients diagnosed with DCIS (1991-2002) by means of needle-localised open breast biopsy (NLBB, n=49) and SCNB (n=51) were studied. Both groups were comparable for clinical, radiological and pathological characteristics. The therapeutic interval (time from presentation to definitive of therapy) was 62-days in the SCNB group versus 32-days in the NLBB group (p<0.001). In the SCNB group fewer surgical procedures were required for completion of surgical therapy (p=0.006) and after local excision the surgical margins were more often tumour free (p=0.002). It is postulated that the need for fewer surgical procedures and the greater frequency of tumour-free margins after local excision may be attributable to SCNB.

Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer

BACKGROUND

Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs.

METHODS

EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined.

RESULTS

Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures.

CONCLUSION

EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.

[The biopsying of at least 5 mediastinal lymph node stations for presurgical staging in patients with a non-small-cell lung carcinoma]

OBJECTIVE

To determine the additional value of mediastinoscopy/tomy in the pre-surgical staging of non-small-cell lung carcinoma.

DESIGN

Retrospective.

METHODS

Patients who underwent mediastinoscopy/tomy for staging of non-small-cell lung carcinoma from 1994 to 2000 at Groningen University Hospital, the Netherlands, were evaluated. Starting with data on history, physical examination, data imaging tests and bronchoscopy, the additional value of the mediastinoscopy was then evaluated using a logistic regression model. Not only was the additional value of a limited, routinely performed mediastinoscopy (whereby only lymph nodes at the site of the primary tumour are biopsied) examined, but also that of the comprehensive standard mediastinoscopy (conforming to the minimal requirements regarding number and localization of biopsied lymph nodes, i.e. lymph-node stations 2L, 2R, 4R, 4L, 7). The outcome against which all the test results were measured was the result of final pathological tumour staging.

RESULTS

A total of 176 evaluable patients were included. History, physical examination and bronchoscopy played a small but significant role in predicting the percentage of patients in which resection was possible, 58% (95% CI: 50-67). Age was an important predictor. The subsequent addition of the limited and routinely performed mediastinoscopy to the model increased the correct prediction to 69% (95% CI: 61-77), while adding the standard mediastinoscopy to the model showed a significantly higher correct prediction of 81% (95% CI: 75-88).

CONCLUSION

The standard mediastinoscopy involving a minimum of five different lymph node stations was of greater diagnostic value than limited mediastinoscopy.

Inhibition of neutrophil migration soon after initiation of treatment with leflunomide or methotrexate in patients with rheumatoid arthritis: findings in a prospective, randomized, double-blind clinical trial in fifteen patients

OBJECTIVE

Leflunomide is a novel immunomodulating drug that has recently been approved as a disease-modifying antirheumatic drug for the treatment of rheumatoid arthritis (RA). The aim of this study was to determine the relationship between the clinical effects of leflunomide and neutrophil migration.

METHODS

The effects of leflunomide and methotrexate on neutrophil chemotaxis were studied in 15 RA patients who participated in a prospective, randomized, double-blind clinical trial. When possible, neutrophil numbers were counted in synovial fluid (SF) samples at baseline and after 14 days, 4 months, and 1 year of treatment. The chemotactic properties of peripheral blood neutrophils from RA patients treated with either leflunomide or methotrexate were studied by the Boyden chamber technique, using the activators formyl-methionyl-leucyl-phenylalanine (fMLP) and interleukin-8 (IL-8). The in vitro effects of A77 1726, the active metabolite of leflunomide, and methotrexate on peripheral blood neutrophils from 7 healthy control subjects were also investigated.

RESULTS

Both therapy groups exhibited clinical improvement, including rapid reductions in SF neutrophil counts and reduced joint swelling and tenderness. On day 14, 3 of 7 patients who received leflunomide showed no detectable effusions. There was a significant effect on neutrophil chemotaxis (P < 0.001), which was similar for leflunomide and methotrexate. The direct effects on the neutrophils diminished over time. Incubation of peripheral blood neutrophils from healthy controls with A77 1726 confirmed the inhibitory effect on chemotaxis.

CONCLUSION

Leflunomide treatment is beneficial in RA patients. Different mechanisms are operative in various phases of treatment, leading to decreased recruitment of inflammatory cells in the joints.

Limited influence of pouch function on quality of life after ileal pouch-anal anastomosis

BACKGROUND/AIMS

Despite a high frequency of pouch function disorders, most patients are satisfied with the outcome of ileo-anal pouch surgery. Aims of this study were: 1) To assess the influence of pouch function on quality of life and, 2) to determine which aspects of pouch dysfunction affect quality of life the most.

METHODOLOGY

Questionnaires, addressing current pouch function and quality of life (Rand-36, GIQLI), were sent to all (53) patients with intact ileo-anal pouches, operated on between 1987 and 1997 in our center.

RESULTS

Thirty-six of 53 patients responded. Compared to reference data, Rand-36 scores for role-limitations based on a physical problem, vitality and general health perception were significantly diminished (P < 0.01). Physical and social functioning were normal. The GIQLI score was slightly decreased (111.7 vs. 125.8, P < 0.01). Overall pouch function did not correlate with the overall Rand-36 score, but correlated well with the overall GIQLI score (r = -0.47). Both quality of life scores were diminished mainly by the night-time stool frequency.

CONCLUSIONS

1) Quality of life after IPAA, as measured with validated questionnaires, is only slightly decreased; 2) the GIQLI questionnaire is more sensitive to pouch dysfunction than the Rand-36; 3) night-time stool frequency influences quality of life the most.

Immunohistological analysis of synovial tissue for differential diagnosis in early arthritis

OBJECTIVE

An early diagnosis in patients presenting with arthritis is important to provide information about prognosis and to initiate treatment. The objective of this study was to determine which markers applied in immunohistological analysis of synovial tissue (ST) specimens could be used to differentiate rheumatoid arthritis (RA) from other forms of arthritis.

METHODS

Synovial biopsies were obtained by blind needle techniques from 95 patients with early arthritis. After follow-up of at least 2 yr to verify the diagnosis, the patients could be classified as follows: RA (n=36), undifferentiated arthritis (UA; n=21), osteoarthritis (OA; n=17), reactive arthritis (ReA; n=10), ankylosing spondylitis (AS; n=3), psoriatic arthritis (PsA; n=2) and crystal-induced arthritis (CA; n=6). ST sections were analysed by immunohistochemistry using monoclonal antibodies against CD3, CD4, CD8, CD22 (B cells), CD38 (plasma cells), CD68 (macrophages) and CD55 (fibroblast-like synoviocytes).

RESULTS

Logistic regression analysis revealed that the higher scores for the numbers of CD38+ plasma cells and CD22+ B cells in RA were the best discriminating markers comparing RA to non-RA patients (CD38: P=0.0001; CD22: P<0.05). Polychotomous regression analysis comparing three diagnostic categories (1: RA; 2: UA, ReA, AS and PsA; 3: OA and CA) also identified the score for the number of CD38+ plasma cells (P<0.0001) as well as the numbers of CD68+ macrophages in the synovial sublining (P=0.05) as discriminating markers.

CONCLUSION

The results suggest that immunohistochemical analysis of ST specimens from early arthritis patients can be used to differentiate RA from non-RA patients. The numbers of plasma cells, B cells and macrophages are especially increased in ST of patients with RA. Future studies in early arthritis patients with clinical features which do not allow an immediate confident diagnosis may clarify the role of this test system in differential diagnosis.

The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study

PURPOSE

To answer the question whether a single fraction of radiotherapy that is considered more convenient to the patient is as effective as a dose of multiple fractions for palliation of painful bone metastases.

PATIENTS

1171 patients were randomised to receive either 8 Gy x 1 (n = 585) or 4 Gy x 6 (n = 586). The primary tumour was in the breast in 39% of the patients, in the prostate in 23%, in the lung in 25% and in other locations in 13%. Bone metastases were located in the spine (30%), pelvis (36%), femur (10%), ribs (8%), humerus (6%) and other sites (10%).

METHOD

Questionnaires were mailed to collect information on pain, analgesics consumption, quality of life and side effects during treatment. The main endpoint was pain measured on a pain scale from 0 (no pain at all) to 10 (worst imaginable pain). Costs per treatment schedule were estimated.

RESULTS

On average, patients participated in the study for 4 months. Median survival was 7 months. Response was defined as a decrease of at least two points as compared to the initial pain score. The difference in response between the two treatment groups proved not significant and stayed well within the margin of 10%. Overall, 71% experienced a response at some time during the first year. An analysis of repeated measures confirmed that the two treatment schedules were equivalent in terms of palliation. With regard to pain medication, quality of life and side effects no differences between the two treatment groups were found. The total number of retreatments was 188 (16%). This number was 147 (25%) in the 8 Gy x 1 irradiation group and 41 (7%) in the 4 Gy x 6 group. It was shown that the level of pain was an important reason to retreat. There were also indications that doctors were more willing to retreat patients in the single fraction group because time to retreatment was substantially shorter in this group and the preceding pain score was lower. Unexpectedly, more pathological fractures were observed in the single fraction group, but the absolute percentage was low. In a cost-analysis, the costs of the 4 Gy x 6 and the 8 Gy x 1 treatment schedules were calculated at 2305 and 1734 Euro respectively. Including the costs of retreatment reduced this 25% cost difference to only 8%. The saving of radiotherapy capacity, however, was considered the major economic advantage of the single dose schedule.

CONCLUSION

The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A more detailed analysis of the study is in progress.

Asymptomatic synovitis precedes clinically manifest arthritis

OBJECTIVE

It has been hypothesized that asymptomatic synovitis may precede clinical manifestations of arthritis in the earliest phase of rheumatoid arthritis (RA). To obtain more insight into this disease phase, we investigated the immunohistologic features of synovial tissue (ST) from the knee joints of rhesus monkeys with induced arthritis and from RA patients with both clinically involved and clinically uninvolved knee joints.

METHODS

Serial ST biopsy specimens from the knee joints of 4 rhesus monkeys that had been immunized with type II collagen and ST from 10 RA patients were investigated. Eight patients without inflammatory joint disease served as controls.

RESULTS

In ST from immunized monkeys, an influx of macrophages was observed well before the occurrence of arthritis. Signs of inflammation were also demonstrated in ST from clinically uninvolved knee joints of all RA patients evaluated. The ST was characterized in particular by infiltration with macrophages and by the expression of macrophage-derived cytokines.

CONCLUSION

The findings support the view that asymptomatic synovitis precedes clinically manifest arthritis in both early and established RA. This implies that the debut of RA already represents a chronic phase of the disease.

[The increase in cohabitation: changes in related demographic behavior]

"The Dutch period- and age-specific hazard rates of marriages, cohabitation, [and] dissolution of cohabitation are studied. Also, family formation according to living arrangement of the mother is examined. The number of cohabiting persons has risen markedly.... Rates of direct marriage have declined.... The increased period of cohabitation is mainly linked with a delay in marriage among young cohabitors; it does, however, not coincide with a decreasing risk dissolution.... Fertility rates of married women have risen across the birth cohorts, while fertility rates of cohabiting women and women living without partner have remained fairly stable." (SUMMARY IN ENG)