Mapping area variability in social and behavioural difficulties among Glasgow pre-schoolers: linkage of a survey of pre-school staff with routine monitoring data

BACKGROUND

Social, emotional and behavioural development in early to middle childhood impact upon many outcomes in future life and are influenced by home, neighbourhood and school environments. We used linked data to investigate differences between areas in Glasgow City in level of difficulties in pre-school age children, after consideration of demographics, including area-level deprivation.

METHODS

Pre-school education staff completed Strengths and Difficulties Questionnaires (SDQ) on all children progressing to school from a local authority or partnership (local authority-funded private) pre-school in Glasgow City between 2010 and 2012. These data were linked to individual (age, gender) and area-level (deprivation) demographics from the City Council Education Services Department. Statistical models were fitted to the SDQ scores, adjusting for age, gender, area deprivation, year of school entry, pre-school establishment attended and electoral ward of residence. Correlation between neighbouring wards was incorporated to allow for clustering of scores.

RESULTS

Boys and those living in more deprived areas had higher levels of difficulties. Children aged 5.0-5.5 years had fewest difficulties, while the oldest and youngest children had similar levels of difficulties. There were no significant secular trends by year of school entry. There remained differences among areas after adjusting for these variables, with children living in some areas having fewer difficulties than would be expected based on their socio-demographic characteristics.

CONCLUSIONS

There remained differences in children's levels of difficulties between areas after adjusting for age, gender, area deprivation and year of school entry. Children in some very deprived areas had fewer difficulties than might be expected, while those in relatively affluent areas had more difficulties than expected based on their deprivation level. There may be other, unmeasured, individual- and area-level reasons for children's level of difficulties, and these require further exploration.

The Incorporation of an Advanced Donation Program Into Kidney Paired Exchange: Initial Experience of the National Kidney Registry

The continued growth of kidney paired donation (KPD) to facilitate transplantation for otherwise incompatible or suboptimal living kidney donors and recipients has depended on a balance between the logistics required for patients and the collaborating transplant centers. The formation of chains for KPD and the shipping of kidneys have permitted networks such as the National Kidney Registry (NKR) to offer KPD to patients over a transcontinental area. However, over the last 3 years, we have encountered patient requests for a more flexible experience in KPD to meet their individual needs often due to rigid time constraints. To accommodate these requests, we have developed an Advanced Donation Program (ADP) in which the donor desires to donate by a specific date, but their paired recipient has not yet been matched to a specific donor or scheduled for surgery. After obtaining careful informed consent from both the donor and paired recipient, 10 KPD chains were constructed using an ADP donor. These 10 ADP donors have facilitated 47 transplants, and thus far eight of their paired recipients have received a kidney within a mean of 178 (range 10-562) days. The ADP is a viable method to support time limited donors in a KPD network.

Association between medical home characteristics and staff professional experiences in pediatric practices

BACKGROUND

The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.

METHODS

Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.

RESULTS

Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.

CONCLUSIONS

Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

Factors associated with a patient-centered medical home among children with behavioral health conditions

At some point in their lives, nearly one-half of all American children will have a behavioral health condition. Many will not receive the care they need from a fragmented health delivery system. The patient-centered medical home is a promising model to improve their care; however, little evidence exists. Our study aim was to examine the association between several behavioral health indicators and having a patient-centered medical home. 91,642 children's parents or guardians completed the 2007 National Survey of Children's Health. An indicator for patient-centered medical home was included in the dataset. Descriptive statistics, bivariate tests, and multivariate regression models were used in the analyses. Children in the sample were mostly Male (52 %), White (78 %), non-Hispanic (87 %), and did not have a special health care need (80 %). 6.2 % of the sample had at least one behavioral health condition. Conditions ranged from ADHD (6 %) to Autism Spectrum Disorder (ASD) (1 %). Frequency of having a patient-centered medical home also varied for children with a behavioral health condition (49 % of children with ADHD and 33 % of children with ASD). Frequency of having a patient-centered medical home decreased with multiple behavioral health conditions. Higher severity of depression, anxiety, and conduct disorder were associated with a decreased likelihood of a patient-centered medical home. Results from our study can be used to target patient-centered medical home interventions toward children with one or more behavioral health conditions and consider that children with depression, anxiety, and conduct disorder are more vulnerable to these disparities.

Comparison of referrals for lumbar spine magnetic resonance imaging from physiotherapists, primary care and secondary care: how should referral pathways be optimised?

OBJECTIVE

To compare sensitivity of pathology on imaging between referrals from primary care, physiotherapists, spinal surgeons and other secondary care providers.

DESIGN AND SETTING

A retrospective review of 200 consecutive magnetic resonance imaging (MRI) scans of patients' first presentations to radiology for MR lumbar scanning at a tertiary orthopaedic centre. A scan report was defined as positive if there was any evidence of neural compromise. Fisher's exact 2×2 contingency analyses were performed.

RESULTS

Eighty-seven (44%) scans were positive and 113 (57%) were negative. Forty-four percent of scans requested by general practitioners (GPs) were reported as positive compared with 57% of scans requested by physiotherapists. Only 40% and 20% of scans requested by specialist spinal surgeons and non-spinal team secondary care providers were positive, respectively. Physiotherapist referrals for MRI lumbar spine scans were significantly more likely to be positive compared with GPs (P=0.05), spinal surgeons (P=0.03) and others (P=0.004).

CONCLUSION

When appropriate, referrals via the extended physiotherapy service should be encouraged, rather than referrals directly from GPs. With appropriate training and in the appropriate clinical context, extended physiotherapy services could include inpatients and could accept outpatient referrals from other secondary care providers and not just from GPs; this would improve efficiency and reduce the workload of the radiology department and the spinal surgical unit.

Early parental physical punishment and emotional and behavioural outcomes in preschool children

OBJECTIVE

To determine whether there is an association between being smacked by your main caregiver in the first two years and emotional and behavioural problems at age four.

DESIGN

Secondary analysis of data from the Growing Up in Scotland Prospective Study (GUS).

SETTING

Scotland, UK.

PARTICIPANTS

GUS birth cohort children, whose main caregiver had no concerns about their behaviour at 22 months.

EXPOSURE

Ever smacked by main caregiver in first 22 months, as measured by caregiver self-report at 22 months.

MAIN OUTCOME

Emotional and behavioural problems as measured by parental assessment and the Strengths and Difficulties Questionnaire (SDQ) at 46 months.

RESULTS

Preschool children exposed to main caregiver smacking in the first two years were twice as likely to have emotional and behavioural problems as measured by parental assessment [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.9-3.2; absolute risk reduction (ARR) 17.8%, 95% CI 12.1-23.5] and SDQ (OR 2.5, 95% CI 1.7-3.7; ARR 7.5%, 95% CI 3.7-11.5), as children never smacked by their main caregiver. The association remained significant after adjusting for child age and sex, caregiver age, sex, ethnicity, educational attainment and mental health status, sibling number, structural family transitions and socioeconomic status (adj. OR 2.4, 95% CI 1.8-3.2 for parental assessment and adj. OR 2.2, 95% CI 1.4-3.5 for SDQ).

CONCLUSIONS

Parental use of physical punishment in the first two years may be a modifiable risk factor for emotional and behavioural difficulties in preschool children.

Genetic markers of toxicity from capecitabine and other fluorouracil-based regimens: investigation in the QUASAR2 study, systematic review, and meta-analysis

PURPOSE

Fluourouracil (FU) is a mainstay of chemotherapy, although toxicities are common. Genetic biomarkers have been used to predict these adverse events, but their utility is uncertain.

PATIENTS AND METHODS

We tested candidate polymorphisms identified from a systematic literature search for associations with capecitabine toxicity in 927 patients with colorectal cancer in the Quick and Simple and Reliable trial (QUASAR2). We then performed meta-analysis of QUASAR2 and 16 published studies (n = 4,855 patients) to examine the polymorphisms in various FU monotherapy and combination therapy regimens.

RESULTS

Global capecitabine toxicity (grades 0/1/2 v grades 3/4/5) was associated with the rare, functional DPYD alleles 2846T>A and *2A (combined odds ratio, 5.51; P = .0013) and with the common TYMS polymorphisms 5'VNTR2R/3R and 3'UTR 6bp ins-del (combined odds ratio, 1.31; P = 9.4 × 10(-6)). There was weaker evidence that these polymorphisms predict toxicity from bolus and infusional FU monotherapy. No good evidence of association with toxicity was found for the remaining polymorphisms, including several currently included in predictive kits. No polymorphisms were associated with toxicity in combination regimens.

CONCLUSION

A panel of genetic biomarkers for capecitabine monotherapy toxicity would currently comprise only the four DPYD and TYMS variants above. We estimate this test could provide 26% sensitivity, 86% specificity, and 49% positive predictive value-better than most available commercial kits, but suboptimal for clinical use. The test panel might be extended to include additional, rare DPYD variants functionally equivalent to *2A and 2846A, though insufficient evidence supports its use in bolus, infusional, or combination FU. There remains a need to identify further markers of FU toxicity for all regimens.

Online social network use by health care providers in a high traffic patient care environment

Background

The majority of workers, regardless of age or occupational status, report engaging in personal Internet use in the workplace. There is little understanding of the impact that personal Internet use may have on patient care in acute clinical settings.

Objective

The objective of this study was to investigate the volume of one form of personal Internet use—online social networking (Facebook)—generated by workstations in the emergency department (ED) in contrast to measures of clinical volume and severity.

Methods

The research team analyzed anonymous network utilization records for 68 workstations located in the emergency medicine department within one academic medical center for 15 consecutive days (12/29/2009 to 1/12/2010). This data was compared to ED work index (EDWIN) data derived by the hospital information systems.

Results

Health care workers spent an accumulated 4349 minutes (72.5 hours) browsing Facebook, staff cumulatively visited Facebook 9369 times and spent, on average, 12.0 minutes per hour browsing Facebook. There was a statistically significant difference in the time spent on Facebook according to time of day (19.8 minutes per hour versus 4.3 minutes per hour, P<.001). There was a significant, positive correlation between EDWIN scores and time spent on Facebook (r=.266, P<.001).

Conclusions

Facebook use constituted a substantive percentage of staff time during the 15-day observation period. Facebook use increased with increased patient volume and severity within the ED.

The relationships between asthma control, daytime sleepiness, and quality of life among children with asthma: a path analysis

OBJECTIVES

We aimed to examine the relationships between asthma control, daytime sleepiness, and asthma-specific health-related quality of life (HRQOL) among children with asthma. Path analyses were conducted to test if daytime sleepiness can mediate the effect of asthma control status on asthma-specific HRQOL.

METHODS

160 dyads (pairs) of asthmatic children and their parents were collected for analyses. The Asthma Control and Communication Instrument (ACCI) was used to categorize adequate and poor asthma control status. The Cleveland Adolescent Sleepiness Questionnaire (CASQ) was used to measure children's daytime sleepiness, including sleep in school, awake in school, sleep in evening, and sleep during transport. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale was used to measure asthma-specific HRQOL.

RESULTS

Poorly controlled asthma was associated with daytime sleepiness and impaired asthma-specific HRQOL. Asthma control status was directly associated with asthma-specific HRQOL (P<.05), whereas sleep in school and sleep in evening domains of daytime sleepiness significantly mediated the relationship between poor asthma control and impaired HRQOL (P<.01).

CONCLUSIONS

Asthma control status was associated with pediatric asthma-specific HRQOL, and the association was significantly mediated by daytime sleepiness. Healthcare providers need to address pediatric sleep needs related to poor asthma control to reduce the negative impact on HRQOL.

Insula and orbitofrontal cortical morphology in substance dependence is modulated by sex

BACKGROUND AND PURPOSE

Frontolimbic circuits are involved in learning and decision-making processes thought to be affected in substance-dependent individuals. We investigated frontolimbic cortical morphometry in substance-dependent men and women and determined whether morphometric measurements correlated with decision-making performance.

MATERIALS AND METHODS

Twenty-eight abstinent SDI (17 men/11 women) were compared with 28 controls (13 men/15 women). Cortical thicknesses and volumes were computed by using FreeSurfer. After controlling for age and intracranial volume, group and sex effects were analyzed in 3 a priori regions of interest: the insula, orbitofrontal cortex, and anterior cingulate cortex by using analysis of covariance. A secondary whole-brain analysis was conducted to verify region-of-interest results and to explore potential differences in other brain regions.

RESULTS

Region-of-interest analyses revealed a main effect of group on the left insula cortex, which was thinner in SDI compared with controls (P = .02). There was a group by sex interaction on bilateral insula volume (left, P = .02; right, P = .001) and right insula cortical thickness (P = .007). Compared with same-sex controls, female SDI had smaller insulae, whereas male SDI had larger insulae. Neither ACC nor OFC significantly differed across group. Performance on a decision-making task was better in controls than SDI and correlated with OFC measurements in the controls.

CONCLUSIONS

SDI and controls differed in insula morphology, and those differences were modulated by sex. No group differences in OFC were observed, but OFC measurements correlated with negative-reinforcement learning in controls. These preliminary results are consistent with a hypothesis that frontolimbic pathways may be involved in behaviors related to substance dependence.

Disruptive behaviour disorders: a systematic review of environmental antenatal and early years risk factors

Disruptive behaviour disorders (DBDs), including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) are chronic disorders with significant overlap in aetiology and presentation. An integrative examination of environmental risk factors is lacking. Six literature searches of web-based bibliographic databases were completed to identify literature on DBDs in general and five disorders in particular: CD, ODD, ADHD, deficits of attention, motor control and perception, and reactive attachment disorder. Searches were filtered to focus on studies including diagnostic assessment, focussing on environmental risk and protective factors in the first 4 years of life. The database searches generated 9806 papers of which 47 were reviewed after filters had been applied. The evidence suggests links between a number of early life risk factors and DBDs, including prenatal cigarette smoking and alcohol use, prenatal viral illness, maternal stress and anxiety, low birthweight, peri-partum and early neonatal complications, parental stress and parenting styles in infancy, early deprivation, adoption and separation. Despite the understanding that there is sharing of risk factors between the DBDs, there has been a disproportionate focus on the role of certain risk factors at the expense of others and the field is weakened by difficulties in controlling for all potential confounding variables.

Matching parenting support needs to service provision in a universal 13-month child health surveillance visit

BACKGROUND

The Glasgow Parenting Support Framework is an intervention to support families with preschool children. It provides structured support through universal and targeted interventions. Two routine family visits by health visitors have been piloted, one involving a home assessment when the child is 13 months old.

AIMS

To establish the need for parenting support in the population at 13 months and whether or not the home assessment improved the match of service provision to need.

METHODS

Health visitors were asked to collect data on existing problems and service provision to families, the mental state of the child's principal carer, an observation of the parent-child relationship and details of management plans. Data from the Child Health Surveillance System were also used.

RESULTS

Data were obtained for 549 families. Nine families were noted to have problems in the parent-child relationship. Carers in these families had poorer mental health. In all, 20% of families had a revisit scheduled: they were also more likely to have poor mental health. All families with possible problems in the relationship had a revisit scheduled. Depression scores measured during the pilot were a significant predictor of revisiting and referral, with an odds ratio of 1.37 for every one point increase in score on the Adult Wellbeing Scale depression subscale.

CONCLUSIONS

Current service provision matches need to some extent but routine visits focused on parenting difficulties at 13 months, particularly parental depression, may help to identify families needing support who would not otherwise have received it.

Quantum dynamics of a Bose superfluid vortex

We derive a fully quantum-mechanical equation of motion for a vortex in a 2-dimensional Bose superfluid in the temperature regime where the normal fluid density ρ(n)(T) is small. The coupling between the vortex "zero mode" and the quasiparticles has no term linear in the quasiparticle variables--the lowest-order coupling is quadratic. We find that as a function of the dimensionless frequency Ω=ℏΩ/k(B)T, the standard Hall-Vinen-Iordanskii equations are valid when Ω≪1 (the "classical regime"), but elsewhere, the equations of motion become highly retarded, with significant experimental implications when Ω≳1.

Factors associated with perceived barriers to pediatric palliative care: a survey of pediatricians in Florida and California

PURPOSE

The provision and uptake of pediatric palliative care continues to be plagued by barriers. Several studies have documented these barriers, but none have done so with a diverse sample (most are at a single institution) or specifically about pediatric palliative care. Moreover, none have investigated the factors associated with perceived barriers. Our study has two aims: (1) to describe the barriers to pediatric palliative care as reported by a group of pediatricians practicing in two large States in the US; and (2) to identify factors associated with these perceived barriers.

METHODS

Cross-sectional survey data were collected from 303 pediatricians in Florida and California.

RESULTS

The two greatest barriers reported by the pediatricians were related to families' reluctance to accept palliative care (95%) and families viewing palliative care as giving up (94%). Only 42% of pediatricians noted that reimbursement was a barrier. Across all the regressions, three factors were consistently associated with barriers to palliative care: race/ethnicity of pediatrician practice setting, and the percentage of low-income patients.

CONCLUSIONS

Our findings can be used to develop targeted educational interventions towards providers and families. Understanding the factors that are driving the low uptake in palliative care is the first step in advancing pediatric palliative care overall.

TEMPO EC for the enumeration of Escherichia coli in foods: collaborative study

The automated method for enumeration of Escherichia coli, TEMPO EC, in foods uses a dehydrated culture medium and enumeration card containing 48 wells across three different dilutions for the automatic determination of the most probable number (MPN). The alternative method was compared in a multilaboratory collaborative study to AOAC Official Method 966.24. Six food types were artificially contaminated with E. coli: raw ground beef, bagged lettuce, cooked chicken, pasteurized crabmeat, frozen green beans, and pasteurized whole milk. All foods were analyzed for E. coli counts by 11 collaborating laboratories throughout the United States. Test portions from the six food types each contaminated at four different contamination levels were evaluated. The study demonstrated that the TEMPO EC method is a reliable, automated assay for the enumeration of E. coli in foods.

Flow cytometric evaluation of boar semen by the sperm chromatin structure assay as related to cryopreservation and fertility

Boar semen from a heterospermic mating trial and semen cryopreserved by various methods were evaluated by the flow cytometric sperm chromatin structure assay (SCSA), which measures the susceptibility of sperm nuclear DNA to acid-induced denaturation in situ. Spermatozoa were treated with a pH 1.4 buffer and then stained with the metachromatic dye acridine orange. Acridine orange intercalated into double-stranded DNA (native) fluoresces green while single-stranded DNA (denatured) fluoresces red when excited with 488 nm light. The ratio of red to total fluorescence provides an index of normality/abnormality. The SCSA data on neat boar semen or semen in either Kiev-Merck or Pursel-Johnson extender and frozen directly on dry ice blocks or plunged into LN2 did not differ within individual boars. Therefore, chromatin structure, as measured by the SCSA, was not influenced differently by these 2 methods of semen cryopreservation. When semen from 6 boars was mixed in equal sperm numbers in six 3-way combinations and inseminated into at least 3 Duroc gilts per combination, 4 of the 6 combinations yielded 2 litters, while the remaining 2 combinations yielded 3 litters. The SCSA correctly predicted both the high and low fertility boars based on a ratio of offspring as deviated from the theoretical percentage. Thus, the SCSA was found to be a valuable adjunct method for evaluating boar semen quality.

Easy-to-use rapid test for direct detection of Campylobacter spp. in chicken feces

Human campylobacteriosis is the leading cause of acute bacterial gastroenteritis in developed countries. One important source of infection is poultry. Results from the Dutch Campylobacter Risk Management and Assessment project indicate that meat from broiler flocks shedding >or=7 log CFU Campylobacter per g of feces poses the greatest risk of transmitting campylobacteriosis. The objective of this study was to develop a simple and rapid test that would identify chicken flocks shedding high numbers of Campylobacter. We used lateral flow technology as the alternative test method, and selected the culture method according to International Organization for Standardization guidelines. To evaluate the test under field conditions, we sampled either chicken droppings at farms or cecal contents at the slaughterhouse. PCR was used to confirm presumptive Campylobacter spp. colonies. Under laboratory conditions, chicken feces containing >or=6.7 log CFU/g Campylobacter jejuni or >or=7.1 log CFU/g Campylobacter coli were identified by the lateral flow test. Overall, 3 (33%) of 10, and 29 (85%) of 34 C. jejuni- or C. coli-positive chicken flocks were identified at farms and slaughterhouses, respectively, by using the lateral flow test. Fecal samples containing >or=7.3 log of C. jejuni or C. coli CFU/g as determined by plating were always positive when using the lateral flow test. A single person testing seven flocks at a time could obtain test results within 2 h of sampling. This simple and rapid lateral flow test may contribute significantly to the identification of chicken flocks shedding high numbers of Campylobacter.

Association of molecular markers with toxicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trial

PURPOSE

Predicting efficacy and toxicity could potentially allow individualization of cancer therapy. We investigated putative pharmacogenetic markers of chemotherapy toxicity in a large randomized trial.

PATIENTS, MATERIALS, AND METHODS

Patients were randomly assigned to different sequences of chemotherapy for advanced colorectal cancer. First-line therapy was fluorouracil (FU), irinotecan/FU (IrFU) or oxaliplatin/FU (OxFU). Patients allocated first-line FU had planned second-line irinotecan alone, IrFU, or OxFU. The primary toxicity outcome measure was toxicity-induced delay or dose reduction; the secondary outcome was Common Terminology Criteria of Adverse Events grade >or= 3 toxicity. DNA was analyzed in 1,188 patients; 1,036 were assessable for the primary outcome, including 688 treated with FU, 270 with IrFU (first or second line), 280 with OxFU (first or second line), 184 with irinotecan alone, and 454 with any irinotecan-containing regimen. Ten polymorphisms were assessed: thymidylate synthase-enhancer region (TYMS-ER), thymidylate synthase 1494 (TYMS-1494), dihydropyrimidine dehydrogenase (DPYD), methylenetetrahydrofolate reductase (MTHFR), mutL homolog 1 (MLH1), UDP glucuronyltransferase (UGT1A1), ATP-binding cassette group B gene 1 (ABCB1), x-ray cross-complementing group 1 (XRCC1), glutathione-S-transferase P1 (GSTP1), and excision repair cross-complementing gene 2 (ERCC2). Results Using the primary outcome measure, no polymorphism was significantly associated (P < .01) with the toxicity of any regimen or with the difference in toxicity of IrFU or OxFU versus FU alone. Trends (of doubtful significance) were seen for associations of XRCC1, ERCC2, and GSTP1 with toxicity during irinotecan regimens: XRCC1, primary end point, any irinotecan-containing regimen (P = .045); ERCC2, secondary end point, irinotecan alone (P = .003); GSTP1, secondary end point; IrFU (P = .039); and irinotecan alone (P = .05). There was no evidence of association of UGT1A1*28 with irinotecan toxicity.

CONCLUSION

These results do not support the routine clinical use of the evaluated polymorphisms, including UGT1A1*28. Further investigation of XRCC1, ERCC2, and GSTP1 as potential predictors of irinotecan toxicity is warranted.

Paediatricians' perceptions on referrals to paediatric palliative care

Children have traditionally been referred to palliative care when curative treatments were exhausted. Recently, experts have suggested that children could benefit from palliative care early in their courses of illness. Using survey data from 303 paediatricians in Florida and California, this study assesses if paediatricians would refer children to palliative care early in their course of illness. Results showed that more years in practice were associated with decreased odds of referring children to palliative care. Academic practice setting and more Medicaid patients were associated with greater odds of referral prior to the end of life. Hispanic paediatricians, those with more experience and those who practice in a hospital setting were associated with decreased odds of referral prior to the end of life. Results suggest that health planners who wish to implement or refine integrated paediatric palliative care programs should consider outreach strategies targeted at paediatricians with specific characteristics.

Understanding the Advanced Signal Processing Technique of Real-Time Adaptive Filters

Diagnostic ultrasound manufacturers are advancing the technology of sonographic systems, providing superior image quality and improving the diagnostic confidence for both sonographers and radiologists. Real-time adaptive filters (RTAFs) are perhaps the least known among the advanced signal processing techniques available on most modern sonography machines, which is further complicated by the fact that RTAF appears under various trademark names. Despite the different proprietary names, RTAFs generally employ a postprocessing mathematical algorithm to real-time imaging that improves contrast resolution by reducing noise and artifacts while simultaneously enhancing the edges and smoothing the tissue texture of structures. This technique may be applied across a wide variety of clinical examinations and may not yet be completely understood and appreciated by sonographers. This review aims to educate readers on how RTAFs work, supported by examples of their benefit to image quality. In particular, the authors describe the effectiveness of using RTAF for superficial structures (thyroid, abdominal wall), deep structures (abdomen, pelvis), and dynamic examinations, including musculoskeletal and vascular applications.

Home-based infusion therapy for patients with Fabry disease

Fabry disease is an inherited, progressive, life-threatening disease; therefore, lifelong therapy is needed. By replacing the deficient enzyme, disease progression may be delayed or halted, thereby avoiding serious complications. Hospital-based agalsidase therapy is generally perceived as inconvenient and home-based infusion therapy is greatly appreciated by patients, their families and healthcare professionals. Patients can get familiar with infusion therapy in a hospital setting and, if specific requirements are fulfilled, routine nurse-assisted infusion, or self-care, at the patient's home can be organized. A stable patient who tolerates the infusion and a suitable home environment are prerequisites for home therapy. The authors' clinical experiences underscore the safety and practicality of home therapy. In addition to a major positive impact on the patient's quality of life, home infusion therapy may reduce the constraints of hospital resources. This article reviews the collective experiences with agalsidase beta home infusion therapy and outlines how safe, patient-centred homecare can be organized. Home infusion therapy with Fabrazyme should not be withheld from patients considered eligible according to the proposed criteria. Similar approaches to other enzyme therapies are also possible.