Parent-child interaction therapy with physically abusive parents: efficacy for reducing future abuse reports

A randomized trial was conducted to test the efficacy and sufficiency of parent-child interaction therapy (PCIT) in preventing re-reports of physical abuse among abusive parents. Physically abusive parents (N=110) were randomly assigned to one of three intervention conditions: (a) PCIT, (b) PCIT plus individualized enhanced services, or (c) a standard community-based parenting group. Participants had multiple past child welfare reports, severe parent-to-child violence, low household income, and significant levels of depression, substance abuse, and antisocial behavior. At a median follow-up of 850 days, 19% of parents assigned to PCIT had a re-report for physical abuse compared with 49% of parents assigned to the standard community group. Additional enhanced services did not improve the efficacy of PCIT. The relative superiority of PCIT was mediated by greater reduction in negative parent-child interactions, consistent with the PCIT change model.

The effect of different oral antibiotics on the gastrointestinal microflora of a wild rodent (Aethomys namaquensis)

Gut sterilization via the oral administration of antibiotics facilitates physiological studies of the nutritionally important relationship between intestinal microflora and the host. However, the composition of gut flora is extremely variable, and as a result, the efficacy of antibiotics in achieving gut sterilization varies considerably between species. We tested the effectiveness of three antibiotic cocktails in sterilizing the gut of a rodent pollinator, the Namaqua rock mouse (Aethomys namaquensis). The cocktails were (1) streptomycin sulfate and bacitracin (previously used with domestic mice and rats), (2) chloramphenicol and bacitracin (based on antibiotic screening tests performed on faecal flora) and (3) Baytril 10% oral solution (a veterinary antimicrobial agent containing enrofloxacin). We tested for antibiotic inactivation by determining bacterial viability through fluorescence staining of faecal samples. We also tested techniques to maintain sterility during antibiotic treatment without the benefit of a laminar flow cabinet. Antibiotics were administered orally in food and water consumed ad libitum over 4 consecutive days. Antibiotic effectiveness was assessed by culturing anaerobic bacteria from faecal samples collected before and after each antibiotic treatment. Treatment with Baytril 10% oral solution eliminated or significantly reduced faecal flora, whereas other antibiotics did not. This study clearly demonstrates the importance of testing the effectiveness of antibiotics before their use in studies that involve antibiotic-treated subjects, particularly if these are species previously untested.

Variable penetrance of a familial progressive necrotising encephalopathy due to a novel tRNA(Ile) homoplasmic mutation in the mitochondrial genome

INTRODUCTION

We present a family comprising a clinically normal mother and two daughters, each with severe encephalopathy with onset in late childhood. A third daughter had died previously of an earlier onset but neuropathologically similar disease.

METHODS

Sequence analysis of the entire mtDNA was carried out in muscle, fibroblasts, and lymphocytes of the affected daughters and unaffected mother. Biochemical analysis of individual respiratory chain enzymes was performed on the same tissues, and on several transmitochondrial cybrid clones containing the nucleus of a 143B.206 osteosarcoma cell line and the mutant mtDNA.

RESULTS

Genetic analyses revealed in both daughters and mother the presence of a novel mutation in the tRNA(Ile) gene of mtDNA, which was homoplasmic in fibroblasts, lymphocytes, and skeletal muscle of the two patients. It was also homoplasmic in fibroblast and skeletal muscle samples of the mother, and approximately 97% heteroplasmic in her lymphocytes. Combined defects of complexes I and IV of the mitochondrial respiratory chain were found not only in fibroblasts of the two probands, but surprisingly also in those of their clinically unaffected mother. The respiratory chain defect segregated in transmitochondrial cybrids containing the nucleus of a 143B.206 osteosarcoma cell line and the mutant mtDNA, indicating that the latter was responsible for the biochemical phenotype.

DISCUSSION

Our results support the concept that homoplasmic mutations in tRNA genes can be responsible for mitochondrial disorders characterised by extremely variable penetrance. Albeit still unexplained, this phenomenon has important consequences in the nosological characterisation, clinical management, and genetic counselling of mitochondrial disorders.

Understanding the Burden of Stress Urinary Incontinence in Europe: A Qualitative Review of the Literature

OBJECTIVE

This study was undertaken to better define the prevalence, risk factors, as well as the economic and human burden of stress urinary incontinence (SUI) in Europe that will help health care providers better understand the impact of this condition.

METHODS

A literature search was performed using MEDLINE, EMBASE, BIDS, HealthStar, HSRProj, and HSTAT databases to review the European literature (France, Germany, Italy, Spain, UK) on SUI between 1990 and 2001. Clinical experts on UI provided advice on this review.

RESULTS

In all European countries studied SUI was identified as a distinct and highly prevalent form of urinary incontinence, and in some countries, as many as 80% of all incontinent women were diagnosed with SUI. However, epidemiological figures varied widely between studies, due to different definitions of diagnostic criteria and disease states and study designs used. Parity and vaginal birth were identified as major risk factors for developing SUI. Only a few studies have examined the economic burden of SUI, but have found it to be significant on patients and society. SUI also significantly affects the quality of women's lives.

CONCLUSION

There is a clear need for harmonisation in defining SUI, standardising survey methods and validation criteria, and outcome measures, if results are to be compared with any validity. A better understanding of the burden of SUI is essential for future research.

Parent-child interaction therapy with physically abusive parents: efficacy for reducing future abuse reports

A randomized trial was conducted to test the efficacy and sufficiency of parent-child interaction therapy (PCIT) in preventing re-reports of physical abuse among abusive parents. Physically abusive parents (N=110) were randomly assigned to one of three intervention conditions: (a) PCIT, (b) PCIT plus individualized enhanced services, or (c) a standard community-based parenting group. Participants had multiple past child welfare reports, severe parent-to-child violence, low household income, and significant levels of depression, substance abuse, and antisocial behavior. At a median follow-up of 850 days, 19% of parents assigned to PCIT had a re-report for physical abuse compared with 49% of parents assigned to the standard community group. Additional enhanced services did not improve the efficacy of PCIT. The relative superiority of PCIT was mediated by greater reduction in negative parent-child interactions, consistent with the PCIT change model.

Finding solutions through empowerment: a preliminary study of a solution-orientated approach to nursing in acute psychiatric settings

Acute inpatient care is not a therapeutic milieu, perhaps owing to the lack of nursing skills. Solution-focused therapy (SFT) has been successful in US inpatient facilities in relation to both objective and subjective 'measures'. This paper reports a study of SFT in a UK context, with the aim of developing a user-friendly SFT training course and assessing its impact on both nurses and clients, via a multifaceted, triangulated data collection design. Nurses' knowledge and clinical performance were assessed, as was the client's perspective. There was a significant difference in nurses' SFT knowledge after training and strong evidence of the model being used in practice during the course of training, although nursing documentation was not fully completed. Eighty-three per cent of nurses said that they would continue using the model, and clients found the SFT approach helpful. The findings match the US experience of using SFT.

Dopaminergic drug effects on physiological connectivity in a human cortico-striato-thalamic system

Cortico-striato-thalamic (CST) systems are anatomical substrates for many motor and executive functions and are implicated in diverse neuropsychiatric disorders. Electrophysiological studies in rats, monkeys and patients with Parkinson's disease have shown that power and coherence of low frequency oscillations in CST systems can be profoundly modulated by dopaminergic drugs. We combined functional MRI with correlational and path analyses to investigate functional and effective connectivity, respectively, of a prefronto-striato-thalamic system activated by object location learning in healthy elderly human subjects (n = 23; mean age = 72 years). Participants were scanned in a repeated measures, randomized, placebo-controlled design to measure modulation of physiological connectivity between CST regions following treatment with drugs which served both to decrease (sulpiride) and increase (methylphenidate) dopaminergic transmission, as well as non-dopaminergic treatments (diazepam and scopolamine) to examine non-specific effects. Functional connectivity of caudate nucleus was modulated specifically by dopaminergic drugs, with opposing effects of sulpiride and methylphenidate. The more salient effect of sulpiride was to increase functional connectivity between caudate and both thalamus and ventral midbrain. A path diagram based on prior knowledge of unidirectional anatomical projections between CST components was fitted satisfactorily to the observed inter-regional covariance matrix. The effect of sulpiride was defined more specifically in the context of this model as increased strength of effective connection from ventral midbrain to caudate nucleus. In short, we have demonstrated enhanced functional and effective connectivity of human caudate nucleus following sulpiride treatment, which is compatible both with the anatomy of ascending dopaminergic projections and with electrophysiological studies indicating abnormal coherent oscillations of CST neurons in parkinsonian states.

Maintaining hydraulic control using deep rooted tree systems

Groundwater phytotechnology systems are currently being used to control the migration of contaminant plumes and remove groundwater that flows into containment areas. Trees in such systems function by reducing recharge and using groundwater via transpiration. A stand of deep-rooted trees can act as a biological "pump", removing a substantial amount of water from the saturated zone. Depth to groundwater compared to rooting depth is an important consideration. Many useful tree species are not naturally deep-rooted, but various cultural practices can produce trees with roots that are deep enough to tap into the water table. Hydraulic control can be calculated or modeled using equations that compare transpired water to groundwater flow and take into account site-specific geologic and climatic variables. However, field measurements should be carried out whenever possible to obtain more precise estimates of groundwater capture and control.

Preliminary investigations into possible resistance to oxytetracycline in Melissococcus plutonius, a pathogen of honeybee larvae

AIMS

To investigate the occurrence of oxytetracycline (OTC) resistance in Melissococcus plutonius, which causes European foulbrood in honeybee colonies.

METHODS AND RESULTS

Strains of M. plutonius were isolated from diseased colonies in England and Wales and tested for resistance to OTC. The minimum inhibitory concentration (MIC) of OTC was also determined for selected isolates. No resistance to the antibiotic was found in any isolate and the average MIC was found to be 3.9 microg ml-1. Melissococcus plutonius was found to be susceptible to both chlortetracycline and tetracycline.

CONCLUSIONS

No resistance to OTC was found in M. plutonius.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrated that OTC can continue to be used to treat European foulbrood and that resistance may not explain why some treatments fail.

Use of resistance-area product derived from Doppler MCA velocity to estimate the range of active cerebrovascular regulation

The purpose of the present study was to explore the development of a method to estimate the range of active cerebrovascular regulation using resistance-area product (RAP) derived from transcranial Doppler ultrasound recordings of middle cerebral artery blood velocity (MCAV) obtained before and after physiologic challenge. Intracranial pressure (ICP), arterial blood pressure (ABP), and MCAV were monitored on 9 patients before and after challenges with either Noradrenlin or CO2 inhalation. One patient was monitored at 24, 48, 72, and 96 hrs. For each cardiac cycle a value of RAP was computed from the inverse of the slope of the regression line of paired values of aligned MCAV and ABP recordings. Mean values of percent change of difference of RAP (% delta RAP) versus change of cerebral perfusion pressure (CPP) were computed. Theoretical values of % delta RAP were derived from reported lab values of percent change diameter of arterioles versus ABP. Of the nine patients, 22% (2/9) demonstrated either impaired dilation and/or constriction. Furthermore, the correlation between theoretical and experimental values of % delta RAP and CPP (n = 34) was strong (r = .86, p < .005). The serially-monitored patient failed to dilate during all CO2 challenges and to fully constrict to the Noradrenlin challenge at 72 hrs. % delta RAP associated with corresponding changes of CPP may have value as a clinical method to estimate the range of active cerebrovascular regulation.

Oestrogens for urinary incontinence in women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (November 2002) and the reference lists of relevant articles. Date of the most recent searches: November 2002.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urge or mixed incontinence or other urinary symptoms.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers. Data were extracted by all three reviewers and cross checked. Trial results were analysed within clinical subgroups or by intervention. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Twenty eight trials were identified which included 2926 women. Sample sizes ranged from 16 to 1525. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of trials. In the 15 trials that compared oestrogen with placebo, 374 women received oestrogen and 344 placebo. Subjective impression of cure was higher amongst those treated with oestrogen for all categories of incontinence (36/101, 36% versus 20/96, 21%; RR for cure 1.61, 95% CI: 1.04 to 2.49). When subjective cure and improvement were considered together, a statistically higher cure and improvement rate was shown for both urge (35/61, 57% versus 16/58, 28% on placebo) and stress (46/107, 43% versus 29/109, 27%) incontinence. For women with urge incontinence, the chance of cure or improvement was approximately a quarter higher again than in women with stress incontinence. Taking all trials together, the data suggested that about 50% of women treated with oestrogen were cured or improved compared with about 25% on placebo. Overall, there were around 1 to 2 fewer voids in 24 hours amongst women treated with oestrogen. The effect again appeared to be larger amongst women with urge incontinence. There were no statistically significant differences in respect of frequency, nocturia or urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea. In a large trial conducted amongst women with heart disease, data from a subset who had incontinence suggested that women treated with a combination of oestrogen and a progestogen had lower subjective cure or improvement rates compared to the placebo group (RR 0.85, 95% CI 0.76 to 0.95). The data were too few to address other questions about oestrogens compared with, or in combination with, other treatments, different types of oestrogen or different modes of delivery.

REVIEWER'S CONCLUSIONS

Oestrogen treatment can improve or cure incontinence and the evidence suggests that this is more likely with urge incontinence. There was little evidence from the trials after oestrogen treatment had finished and none about long-term effects. Combined oestrogen and progesterone appeared to reduce the likelihood of cure or improvement. There were too few data to address reliably other aspects of oestrogen therapy such as oestrogen type, dose and route of administration. However, the risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in women with an intact uterus.

Blindness following medial maxillectomy

Medial maxillectomy via lateral rhinotomy approach is used in the treatment for tumours affecting the lateral nasal wall. The most frequent complications are crusting, epicanthal scarring and epiphora. The authors report a rare case of blindness secondary to indirect optic neuropathy following medial maxillectomy undertaken to treat a malignant melanoma arising in the lateral nasal wall. It is important to keep in mind, the possibility of this rare complication, while patients are being counselled preoperatively for medial maxillectomy.

Reduced apoptotic levels in squamous but not basal cell carcinomas correlates with detection of cutaneous human papillomavirus

We have investigated the apoptotic levels and expression of the apoptotic inducer Bak in non-melanoma skin cancers. Squamous cell carcinomas of known human papillomavirus status from immunocompetent patients were analysed for the expression of the Bak protein, and the expression profile was compared both to the presence of apoptotic cells and the proliferation marker Ki-67. We demonstrate an inverse correlation between human papillomavirus positivity and Bak expression in squamous cell carcinomas, with concomitantly fewer apoptoic cells being detected in the human papillomavirus positive tumours. Bak expression was not observed in basal cell carcinomas irrespective of human papillomavirus status, suggesting that Bak only plays a role in signalling apoptosis in squamous, but not basal, cell cancers. No differences were observed in the proliferation rates between papillomavirus positive and negative squamous cell tumours. However, a significant decrease in the number of apoptotic cells was observed in human papillomavirus-positive squamous cell carcinomas which suggests that the virus may have significantly altered the relationship between proliferation and apoptosis in a proportion of these tumours.

Transferring people safely with manual handling equipment

OBJECTIVE

To determine whether transferring equipment designed to assist a carer when moving someone who is able to take some weight through their legs is likely to affect the risk of back problems in the carer.

DESIGN

Twelve pieces of equipment were tested by nurses transferring patients from commode to wheelchair and vice versa, and from wheelchair to bed and vice versa. Video recordings were taken of each transfer and freeze-frame pictures at the moment of greatest load were analysed. Compressive disc force was deduced, using a biomechanical model, from the weights of the patient and nurse and measurements of anatomical distances and angles.

SETTING

The Sir Walter Puckey Gait Laboratory, in the Rehabilitation Research Unit, University of Southampton.

SUBJECTS

Six female trained nurses with no recent history of hernia, back pain or pregnancy during the previous six months were recruited to use the equipment. Two female patients were chosen from those volunteering and screened for stroke, confusion and unusual footwear. The patients were able to partially weight-bear and were used to being transferred.

RESULTS

The results indicate that the critical value of 3.4 kN at the L5/S1 disc (specified by the US National Institute for Occupational Safety and Health) was not exceeded when using transferring equipment.

CONCLUSION

In this study, loading on the spine during transferring tasks with or without equipment was not considered harmful when good technique was employed.

Rheumatoid nodule of the nasal septum

Necrotizing granulomatous nodules are a common feature in patients with rheumatoid disease, affecting 20 per cent of seropositive patients. Although most commonly found subcutaneously at points of pressure, these nodules may occur in the connective tissues elsewhere in the body. In the upper aerodigestive tract, nodules have been described in diverse locations, but commonly in the trachea, larynx and the ear. We present the first reported case of a rheumatoid nodule affecting the nasal septum.

Disruption of Trrap causes early embryonic lethality and defects in cell cycle progression

The transactivation/transformation-domain associated protein (TRRAP) belongs to the Ataxia-telangiectasia mutated (ATM) super-family and has been identified as a cofactor for c-MYC-mediated oncogenic transformation. TRRAP and its yeast homolog (Tra1p) are components of histone acetyltransferase (HAT) complexes, SAGA (refs. 2,4,5), PCAF (ref. 3) and NuA4 (ref. 6), which are important for the regulation of transcription and cell cycle progression and also have a role in cell viability. Yet the biological function of this molecule and how it controls proliferation are still unclear. Here we show that null mutation of Trrap in mice results in peri-implantation lethality due to a blocked proliferation of blastocysts. We use an inducible Cre-loxP system to show that loss of Trrap blocks cell proliferation because of aberrant mitotic exit accompanied by cytokinesis failure and endoreduplication. Trrap-deficient cells fail to sustain mitotic arrest despite chromosome missegregation and disrupted spindles, and display compromised cdk1 activity. Trrap is therefore essential for early development and required for the mitotic checkpoint and normal cell cycle progression.

Influence of plasma glutathione levels on radiation mucositis

PURPOSE

To test the hypothesis that there is a link between plasma glutathione (GSH) or other antioxidants (uric acid, ascorbate) and the severity of radiation mucositis following radiation treatment of tumors of the head and neck.

PATIENTS AND METHODS

Patients with carcinomas of the head-and-neck region were treated with the continuous hyperfractionated accelerated radiotherapy (CHART) regimen (54 Gy in 36 fractions over 12 days). Samples of blood plasma were analyzed for GSH, cysteine, urate, and ascorbate by high-pressure liquid chromatography. Patients were graded for dysphagia and requirement for analgesics. The areas under the curves of scores over 2-6 weeks following treatment were computed, and Spearman's rank-correlation coefficient was used to test for an association between plasma GSH levels (or those of other antioxidants) and mucositis.

RESULTS

The pretreatment plasma GSH level in 18 patients scored in the study was 1.0 +/- 0.7 M. Analysis of these and the dysphagia scores produced a correlation coefficient of 0.22 (confidence interval -0.28, 0.61; p = 0.39). No correlation was seen between mucositis severity and other measures of plasma antioxidants: cysteine (7.6 +/- 1.7 M), cysteine + GSH (8.6 +/- 1.9 M), uric acid (317 +/- 86 M), ascorbate (29 +/- 20 M), or whole-blood GSH concentrations (1,010 +/- 239 M).

CONCLUSION

The measurements of approximately micromolar levels of plasma GSH, or about 10 M cysteine + GSH (almost all of the total nonprotein thiols), are consistent with most other published data for either healthy adults or cancer patients; however, the values reported in an earlier study, suggesting a link between GSH and mucositis, are much higher. The hypothesis of a possible link between radiation mucositis and plasma-free (nonprotein) thiols was not supported.

Management of the neck in N0 squamous cell carcinoma of the oral cavity

Mortality in treated squamous cell carcinoma of the oral cavity is most often owing to locoregional failure. In an attempt to improve survival, an aggressive approach to surgical management is often favoured. Although it is generally accepted that the N0 neck should be treated if the risk of micrometastatic disease exceeds 20%, there is little direct support in the literature for this position. A retrospective review of all patients presenting with T1-2, N0 squamous cell carcinoma of the oral cavity treated at the Cancer Control Agency of British Columbia from 1985 to 1994 was conducted. Patients were followed for a minimum of 5 years with documentation of patterns of recurrence and disease-specific survival relative to initial management. The decision regarding management of the neck was frequently made to accommodate treatment of the primary site or reconstructive strategies. Thirteen percent of patients with T1, N0 disease underwent prophylactic neck dissection. No significant difference in outcome was noted in this group. Thirty-three percent of patients with T2, N0 disease underwent prophylactic neck dissection. There was a trend toward improved 5-year survival and lower recurrence rates in the group whose necks were treated, but the difference was not found to be statistically significant. In conclusion, this review showed a trend toward increased survival with prophylactic treatment of the neck in T2, N0 squamous cell carcinoma of the oral cavity, but a larger study would be needed to show a statistically significant benefit.

Case-control study of the health of those looked after by local authorities

AIMS

To assess the health needs and provision of health care to school age children in local authority care.

METHODS

A total of 142 children aged 5 to 16 in local authority care, and 119 controls matched by age and sex were studied. Main outcome measures were routine health care, physical, emotional, and behavioural health, health threatening and antisocial behaviour, and health promotion.

RESULTS

Compared with children at home, those looked after by local authorities were significantly more likely to: experience changes in general practitioner; have incomplete immunisations; receive inadequate dental care; suffer from anxieties and difficulties in interpersonal relationships; wet the bed; smoke; use illegal drugs; and have been cautioned by police or charged with a criminal offence. They also tend to receive less health education. They were significantly more likely to have had a recent hearing or eye sight test, and reported significantly less physical ill health overall.

CONCLUSIONS

The overall health care of children who have been established in care for more than six months is significantly worse than for those living in their own homes, particularly with regard to emotional and behavioural health, and health promotion. In contrast to uncontrolled observational studies we have not found evidence of problems with the physical health of these children.

Achieving clinical governance in Women's Services through the use of the EFQM Excellence Model

Following a brief explanation of the concepts inherent within the European Foundation for Quality Management Excellence Model, the experience of using the framework as a mechanism for delivering clinical governance is described. The framework was utilised by a Women's Services Directorate of an acute National Health Service Trust in the UK, who concluded that the Model was an ideal tool for supporting the delivery of clinical governance. However, this was only the case when a number of factors were taken into consideration. For instance, the Directorate found that the change programme required a phased implementation process, sound leadership, expert facilitation, good information systems, numerous training and development opportunities for managers, teamwork and the application of best practice in relation to project improvement teams. Moreover, the absence of all the aforementioned ingredients had the potential to compromise any successful outcome.

A study of the effects of using different cerebral perfusion pressure (CPP) thresholds to quantify CPP "secondary insults" in children

Little is known about the incidence of secondary insults, particularly cerebral perfusion pressure insults, in children. The objectives of this study were to assess the duration of CPP insults at three different thresholds in children and to relate CPP insults to outcome. Eighteen children (age < 16, median & mean 8 years) admitted to the Neurointensive Care Unit who had ICP, MAP and CPP continuously monitored were studied. Using the Edinburgh secondary insult analysis program, data was scanned for CPP insults at three different thresholds: CPP < 70 mmHg, < 60 mmHg and < 50 mmHg. Outcome was assessed using the Glasgow Outcome Scale. Thirty percent of the time CPP was between 60 and 70 mmHg, 21% of the time CPP was between 50 and 60 mmHg and 8% of the time the CPP was less than 50 mmHg. Compared with adults, there was more than twice the incidence of CPP insults in all threshold groups. BP remained relatively stable above 70 mmHg across all three CPP threshold groups. However, ICP increased slightly on average from about 13-->17 mmHg when CPP decreased from the < 70 to < 60 mmHg group (p < 0.001). There was a marked increase in ICP to greater than 30 mmHg on average in the CPP < 50 mmHg group (p < 0.001). CPP insults less than 70, 60 and 50 mmHg do occur commonly in children, a larger dataset and possibly longer term follow up measures will be needed to identify potentially treatable physiological factors most effecting the outcome of children.

Impact of parental consent and notification policies on the decisions of adolescents to be tested for HIV

Restrictions have been placed on the ability of adolescents to obtain human immunodeficiency virus (HIV) testing independent of their parents. Although some states have given adolescents the right to consent to HIV testing independently, many states have remained silent on the issue or have compromised these rights by providing for parental consent or notification when adolescents seek testing. This article examines existing policies and explores whether policies that require adolescents to obtain parental consent, or that permit or mandate parental notification, may deter them from obtaining needed HIV testing.

Coagulation factor activity during neonatal extra-corporeal membrane oxygenation

OBJECTIVE

To ascertain the activity of major coagulation factors during the first 24 h of extra-corporeal membrane oxygenation (ECMO) used to support hypoxaemic neonates.

DESIGN AND SETTING

A prospective observational study in a regional centre for ECMO and paediatric cardiac surgery, placing 15-20 neonates on ECMO per year.

PATIENTS

Ten neonates receiving ECMO for severe hypoxaemia.

MEASUREMENT AND RESULTS

The activity of major clotting factors, of the inhibitor anti-thrombin III and of markers of blood activation were measured during the first 24 h of neonatal extra-corporeal membrane oxygenation (ECMO) and prior to initiation of ECMO. There was laboratory evidence of factor deficiency and of activation of coagulation at all stages. The initiation of ECMO leads to an initial worsening of coagulopathy, but factor deficiency and abnormal activation of coagulation is also seen prior to ECMO in these very sick neonates.

CONCLUSION

If factor deficiency is to be avoided a pro-active approach is required to rapidly correct factor activity. This would include the use of fresh frozen plasma. The effect of such an approach on outcome is at yet uncertain.

Retinoids inhibit proliferation of human coronary smooth muscle cells by modulating cell cycle regulators

Retinoids inhibit rat vascular smooth muscle cell (VSMC) proliferation in vitro and intimal hyperplasia in vivo. We examined the mechanism of the antiproliferative effect of retinoids on human coronary artery smooth muscle cells (human CASMCs). The RAR ligands all-trans-retinoic acid (atRA) and ethyl-p-[(E)-2-(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthyl)-l-propenyl]-benzoic acid (TTNPB); a pan-RXR/RAR agonist, 9-cis-retinoic acid (9cRA); and the RXR-selective ligand AGN4204 all inhibited DNA synthesis stimulated with platelet-derived growth factor and insulin (IC(50): TTNPB 63 nmol/L, atRA 120 nmol/L, AGN4204 460 nmol/L, 9cRA 1.5 micromol/L). All retinoids blocked cell cycle progression as determined by flow cytometry and inhibited retinoblastoma protein (Rb) phosphorylation. TTNPB, atRA, and AGN4204 inhibited the mitogenic induction of cyclin D1, whereas 9cRA had no effect. None of the retinoids affected the expression of CDK 2, 4, or 6 or cyclin E. All retinoids attenuated mitogen-induced downregulation of CDKI p27(Kip1), a major negative regulator of Rb phosphorylation, partly through stabilizing p27(Kip1) turnover. These data demonstrate that retinoids have antiproliferative activity by modulating G(1) --> S cell cycle regulators in human CASMCs through inhibition of Rb phosphorylation and elevation of p27(Kip1) levels.

Women's health centers and minority women: addressing barriers to care. The National Centers of Excellence in Women's Health

New models of care delivery have been developed to better coordinate and integrate healthcare for women. In the United States, one of the challenges is to incorporate the needs of racial and ethnic minority populations into these newer care paradigms. This paper begins with a brief historical review of the experience of racial and ethnic minorities in the American healthcare system to provide a context for discussing barriers and limitations of more traditional models of women's healthcare. Specific approaches used by National Centers of Excellence in Women's Health are presented as examples of strategies that may be implemented by other communities to address these barriers.

Genetic analysis of the Drosophila Gs(alpha) gene

One of the best understood signal transduction pathways activated by receptors containing seven transmembrane domains involves activation of heterotrimeric G-protein complexes containing Gs(alpha), the subsequent stimulation of adenylyl cyclase, production of cAMP, activation of protein kinase A (PKA), and the phosphorylation of substrates that control a wide variety of cellular responses. Here, we report the identification of "loss-of-function" mutations in the Drosophila Gs(alpha) gene (dgs). Seven mutants have been identified that are either complemented by transgenes representing the wild-type dgs gene or contain nucleotide sequence changes resulting in the production of altered Gs(alpha) protein. Examination of mutant alleles representing loss-of-Gs(alpha) function indicates that the phenotypes generated do not mimic those created by mutational elimination of PKA. These results are consistent with the conclusion reached in previous studies that activation of PKA, at least in these developmental contexts, does not depend on receptor-mediated increases in intracellular cAMP, in contrast to the predictions of models developed primarily on the basis of studies in cultured cells.

Involvement in caregiving and adjustment to death of a spouse: findings from the caregiver health effects study

CONTEXT

Most deaths in the United States occur among older persons who have 1 or more disabling conditions. As a result, many deaths are preceded by an extended period during which family members provide care to their disabled relative.

OBJECTIVE

To better understand the effect of bereavement on family caregivers by examining predeath vs postdeath changes in self-reported and objective health outcomes among elderly persons providing varying levels of care prior to their spouse's death.

DESIGN AND SETTING

Prospective, population-based cohort study conducted in 4 US communities between 1993 and 1998.

PARTICIPANTS

One hundred twenty-nine individuals aged 66 to 96 years whose spouse died during an average 4-year follow-up. Individuals were classified as noncaregivers (n = 40), caregivers who reported no strain (n = 37), or strained caregivers (n = 52).

MAIN OUTCOME MEASURES

Changes in depression symptoms (assessed by the 10-item Center for Epidemiological Studies-Depression [CES-D] scale), antidepressant medication use, 6 health risk behaviors, and weight among the 3 groups of participants.

RESULTS

Controlling for age, sex, race, education, prevalent cardiovascular disease at baseline, and interval between predeath and postdeath assessments, CES-D scores remained high but did not change among strained caregivers (9.44 vs 9.19; P =.76), while these scores increased for both noncaregivers (4.74 vs 8.25; F(1,116) = 14.33; P<.001) and nonstrained caregivers (4.94 vs 7.13; F(1,116) = 4.35; P =.04). Noncaregivers were significantly more likely to be using nontricyclic antidepressant medications following the death than the nonstrained caregiver group (odds ratio [OR], 12.85; 95% confidence interval [CI], 1.02-162.13; P =.05). The strained caregiver group experienced significant improvement in health risk behaviors following the death of their spouse (1.47 vs 0.66 behaviors; F(1,118) = 20.23; P<.001), while the noncaregiver and nonstrained caregiver groups showed little change (0.27 vs 0.27 [P =.99] and 0.46 vs 0.27 [P =.39] behaviors, respectively). Noncaregivers experienced significant weight loss following the death (149.1 vs 145.3 lb [67.1 vs 65.4 kg]; F(1,101) = 8.12; P =.005), while the strained and nonstrained caregiving groups did not show significant weight change (156.2 vs 155.2 lb [70.3 vs 69.8 kg] [P =.41] and 156.2 vs 154.0 lb [70.3 vs 69.3 kg] [P =.12], respectively).

CONCLUSIONS

These data indicate that the impact of losing one's spouse among older persons varies as a function of the caregiving experiences that precede the death. Among individuals who are already strained prior to the death of their spouse, the death itself does not increase their level of distress. Instead, they show reductions in health risk behaviors. Among noncaregivers, losing one's spouse results in increased depression and weight loss.

Cognitive strategies employed in trying to arrange a first date

This article deals with how adolescents go about making a date. It uses a funnelling approach to elicit information which is then studied in more detail in a series of further steps. Study 1 used a short survey to obtain data concerning subjects' (n=410) experience of dating. Thereafter, 47 of these subjects selected situations and actions relevant to their dating experience, from two specially prepared lists. Study 1 provided information concerning the relevance of the lists, their comprehensibility and the frequency with which subjects had encountered specific situations or actions. In Study 2, 287 subjects completed the survey, 73 were selected and given revised versions of the lists. After selecting situations and actions, they were interviewed concerning their choice. Subject's responses are discussed with respect to social cognitive development in adolescence.

Telephone support group intervention for persons with hemophilia and HIV/AIDS and family caregivers

The purpose of this pilot project was to test the feasibility of a telephone support group intervention for persons with hemophilia and HIV/AIDS and for their family caregivers. Their support needs were unique because they did not identify with predominant groups of persons with AIDS and were geographically dispersed from peers. The 12 week intervention involved separate telephone support groups for hemophiliacs and for family caregivers. The two groups, comprised of a predetermined maximum of six people, were co-led by a professional and a peer. The support group for family caregivers involved six people and the group for men with hemophilia included five people, including one peer facilitator and one professional facilitator in each group. The telephone support group discussions were taped, transcribed, and analyzed for prevalent themes. The peer and professional facilitators maintained weekly field notes. All participants reported that the telephone groups had a positive impact on meeting their support needs. They believed that they had benefitted from sharing information and that the support groups had decreased their feelings of isolation and loneliness. Participants, however, contended that the intervention should be longer than 12 weeks.

Troglitazone inhibits formation of early atherosclerotic lesions in diabetic and nondiabetic low density lipoprotein receptor-deficient mice

Peroxisome proliferator-activated receptor-gamma (PPARgamma) is a ligand-activated nuclear receptor expressed in all of the major cell types found in atherosclerotic lesions: monocytes/macrophages, endothelial cells, and smooth muscle cells. In vitro, PPARgamma ligands inhibit cell proliferation and migration, 2 processes critical for vascular lesion formation. In contrast to these putative antiatherogenic activities, PPARgamma has been shown in vitro to upregulate the CD36 scavenger receptor, which could promote foam cell formation. Thus, it is unclear what impact PPARgamma activation will have on the development and progression of atherosclerosis. This issue is important because thiazolidinediones, which are ligands for PPARgamma, have recently been approved for the treatment of type 2 diabetes, a state of accelerated atherosclerosis. We report herein that the PPARgamma ligand, troglitazone, inhibited lesion formation in male low density lipoprotein receptor-deficient mice fed either a high-fat diet, which also induces type 2 diabetes, or a high-fructose diet. Troglitazone decreased the accumulation of macrophages in intimal xanthomas, consistent with our in vitro observation that troglitazone and another thiazolidinedione, rosiglitazone, inhibited monocyte chemoattractant protein-1-directed transendothelial migration of monocytes. Although troglitazone had some beneficial effects on metabolic risk factors (in particular, a reduction of insulin levels in the diabetic model), none of the systemic cardiovascular risk factors was consistently improved in either model. These observations suggest that the inhibition of early atherosclerotic lesion formation by troglitazone may result, at least in part, from direct effects of PPARgamma activation in the artery wall.

A qualitative evaluation of shared leadership barriers, drivers and recommendations

Shared leadership is a management model based on the shared governance philosophy. Assumes those individuals or teams performing tasks are best equipped to provide meaningful improvement. The changing image of the current leadership model is one that resides in relationships rather than with a singular person. The key concepts are accountability, partnership, equity, and ownership. When shared leadership was initiated at St Joseph's Health Care, London, Ontario, in 1998, there was a commitment by management and staff to ensure that it was successfully implemented. In order to determine areas for improvement in the implementation process, continual evaluation is necessary. Reports from various staff members, prior to the project, indicated that the shared leadership implementation plan had not been fully realised. Therefore, a qualitative evaluation project, utilising focus groups and interviews, was completed. The purpose of the study was to identify the drivers, as well as the barriers affecting the implementation process. Several recommendations for improving the process were determined by the participants of the study. The result of the project was a collection of four themes, common to the discussions of barriers, drivers and recommendations. The internalisation of the concepts specific to the shared leadership model was found to be vital. The effectiveness of the council framework, including the council structure, processes and membership was also important. Communication of outcomes arising from the council was crucial. The final theme to be identified included those Humanistic Needs that addressed the relationship aspects of this model. Furthermore, the relationship between these themes was explored in the context of the external forces affecting the shared leadership model.