Two further British families with the 'cryohydrocytosis' form of hereditary stomatocytosis

We describe two families with the 'cryohydrocytosis' form of stomatocytosis. Both show a mild stomatocytic anaemia with Hb levels of 12-16 g/dl and reticulocyte counts of 4.3-24%, with very marked autohaemolysis at refrigerator temperatures and pseudohyperkalaemia as a result of loss of K from red cells on storage at room temperature. The ouabain + bumetanide-insensitive 'passive leak' K influx showed a 'U'-shaped temperature dependence, with a minimum at 23 degrees C. In one family, there was consistent variation in haematological severity within the pedigree. In the other, the parents of the proposita were normal, but all three of her children were affected, consistent with a new mutation of a dominant condition. Cold storage of the red cells led to a very marked increase in osmotic fragility and macrospherocytosis, explaining why a diagnosis of 'hereditary spherocytosis' can easily be reached in these pedigrees.

Qualitative analysis of the care of children in hospital in four countries-Part 2

As part of a large study of the care of children in Australian, British, Indonesian, and Thai hospitals, qualitative methods were used to examine differences influenced by culture. Two groups were surveyed: parents of hospitalized children, and staff caring for them. Vignettes were used to invoke discussion, and content analysis was used to examine the data. Subjects were interviewed singly, or in focus groups. These interviews were audiotaped and transcribed for analysis. This article is the second of a two-part series, and includes results of the staff's interviews and discussion. The parents' results and discussion were published in Part 1 (Shields & King, 2001). Staff in all the countries considered communication with parents to be an important part of care of the hospitalized child, and this was consistent with the parents' responses. Staff were mindful of safe practices, though more so in Australia and Britain than Indonesia and Thailand. Cost of treatment for the parents was an important consideration for staff in Indonesia and Thailand when they were planning care for the child. Cultural constructions were more likely to be considered by the Australian and British staff than the Indonesian and Thai staff, and this may have been influenced by the prevailing culture of medical dominance in those countries.

Introduction of a practice guideline for penicillin skin testing improves the appropriateness of antibiotic therapy

We hypothesized that the introduction of a practice guideline for penicillin skin testing would increase the appropriateness of skin testing and reduce antibiotic costs for patients with a history of penicillin allergy who have infections caused by penicillin-susceptible pathogens. We measured the appropriateness of skin testing and daily antibiotic costs before and after the introduction of a guideline for penicillin skin testing. For patients who had negative results of skin testing and were subsequently treated with a penicillin instead of an alternative antibiotic, we calculated the difference between the actual costs and the projected costs of continuing alternative antibiotics without skin testing. After the guideline was introduced, appropriateness of skin testing increased from 17% to 64%, but daily antibiotic costs did not change. For patients who had negative results of skin testing and who were subsequently treated with a penicillin, there was no difference between actual costs and the projected costs if they had not been skin tested. We conclude that introduction of a guideline for penicillin skin testing increases the percentage of eligible patients who have a skin test, and it does so without increasing costs.

Some experiences with treating thyroid cancer patients

U.S. NRC Regulatory Guide 8.39 provides for the release of patients treated with 131I provided that predetermined calculations indicate that no member of the public will receive a total dose equivalent in excess of 5 mSv (500 mrem). When this condition cannot be met or there are other reasons for keeping the patient hospitalized after treatment, control of contamination and exposure from the patient must be taken into consideration. If the patients are hospitalized following treatment, decontaminating the patient's room after discharge and controlling the exposure potential from the patient are considerations for the hospital radiation safety staff. This paper reviews the experiences from fifty patients treated as inpatients over the past two years.

A survey of patient-provider e-mail communication: what do patients think?

Communication between patients and providers forms the backbone of the patient-provider relationship. Often such communication is strained due to time and space limitations on the part of both patients and providers. Many healthcare organizations are developing secure e-mail communication facilities to allow patients to exchange e-mail messages with their providers. Providers are worried that opening such lines of communication will inundate them with vast quantities of e-mail from their patients. Patients are worried that their messages will be intercepted and read by unauthorized people. In an attempt to determine how a group of internet-active, e-mail-ready patients currently use, or potentially view, the ability to exchange e-mail messages with their health care providers, we distributed a survey via e-mail to over 9500 patients. After determining each patient's e-mail activity level (based on the number of messages sent each day), we asked questions such as: "Have you ever sent e-mail to your provider?" "What issues or concerns have prevented you from sending e-mail messages to your provider?" "If your provider were to tell you that someone in his/her office may screen, read or perhaps reply to your message before he/she sees it, to what extent would you be concerned about this?" and "How would you rate your overall satisfaction with the use of e-mail to communicate with your provider?" Results from the survey indicate that nearly 85% of the patients surveyed send at least one e-mail message per day, but that very few (i.e. 6%) of the patients have actually sent an e-mail message to their provider. Interestingly, over half of the patients indicated that they would like to send their providers e-mail, but that they do not know their provider's e-mail address.

Ten years of breast screening in the Screening Mammography Program of British Columbia, 1988-97

OBJECTIVES

To evaluate 10 years outcomes of the Screening Mammography Program of British Columbia (SMPBC) and determine if breast screening targets were being achieved among women aged 40-80+ years.

SETTING

Organised breast screening programme in British Columbia, Canada.

METHODS

Rates of participation, abnormal referral, cancer detection, and interval cancer were calculated for asymptomatic women receiving an SMPBC mammography from 1988-97.

RESULTS

895,849 screening mammographies were provided to 335,433 women. 51.3% of women were age 50-69 years. Abnormalities were identified on 57,454 screens (6.4%) from which 3304 cancers were detected. Abnormal call rates were higher on first (9.8%), compared with subsequent screens (4.4%) and declined with age: 7.7% at age < 40 to 5.4% for age 70-79 years. Cancer detection rates were higher on first (5.0 per 1000) compared with subsequent screens (2.8 per 1000) and increased smoothly with age from 1.4 to 8.2 per 1000 from age < 40 to age 80 years and older. Twenty per cent of cancers were non-invasive. The median size of invasive cancers was 14 mm and 81% had no axillary lymph node metastases. The 12 month interval cancer rate was 0.6 per 1000 and did not vary significantly with age or screening history. The prevalence to expected incidence ratio was 3.1 for women age 50-79 years.

CONCLUSION

Across a broad range of ages, surrogate indices of screening mammography success have been achieved in a population based, North American, organised breast cancer screening programme.

Early sexual abuse and low cortisol

Post-traumatic stress disorder (PTSD) is a mental health disorder precipitated by a stressful event that produces fear or terror in the individual. Post-traumatic stress disorder studies, particularly in early sexual abuse, have been associated with neuroendocrine dysfunction, most notably the hypothalamic-pituitary-adrenal (HPA) axis. Since the literature on PTSD and neuroendocrine factors in young subjects has been sparse, the present studies were designed to look at the basal functioning of the HPA axis in response to early sexual abuse in girls aged 5 to 7 years. Morning salivary samples were collected for cortisol determination from subjects and controls who were scheduled for a physical exam by their pediatrician. The present study shows that subjects who had been abused within the last couple of months had significantly lower cortisol in comparison to control subjects (age, social economic status and race matched). The data suggest that children may have an impaired HPA axis after early trauma.

An investigation into the quality of life of individuals after laryngectomy

BACKGROUND

Little longitudinal data are available on the general physical, psychological, and social problems experienced as a result of laryngectomy or on the preoperative status of patients in regard to these aspects. In particular, prospective longitudinal data gathered from the same group of subjects over time and examining a variety of such outcomes is rare. This descriptive study addresses these issues.

METHODS

The study investigates the progress of a group of 34 laryngectomees from the preoperative stage up to 6 months after surgery. Medical complications, communication, swallowing, diet, physical, and psychosocial adjustment were measured using both the Short-Form Health Survey (SF-36) and original outcome tools.

RESULTS

A large percentage of subjects demonstrated significant and persistent communication and swallowing problems throughout the period studied. Low preoperative and postoperative scores on the SF-36 demonstrate that this group had a poorer state of general health in many respects than those with serious medical conditions previously documented.

CONCLUSIONS

The results suggest that communication and swallowing difficulties persist for many laryngectomees up to 6 months after surgery and still require further investigation. Poor preoperative and postoperative general health scores indicate that this group may require more long-term social support than is currently being offered to adjust to the laryngectomy.

The perceived effects of parent-led support groups for parents of children with disabilities

Parent-led support groups for parents who have children with disabilities are voluntary organizations with goals to provide social support and information and to foster advocacy. The purpose of this study was to explore parents' perceptions of the effect of parent-led support groups in providing parents with support and knowledge and in improving parents' ability to deal with childhood disability issues. Qualitative methods were used to examine the experiences of members of nine parent-run support groups. From these groups, 20 parents were interviewed about the benefits and limitations of participation in support group. Information was also collected by observing support group meetings and reviewing group documents. Interview, observation, and document data were analysed to identify emerging themes. Results of the study indicated that the effects of belonging to a parent-led parent support group were substantial. Through these groups, parents gain increased skills, an increased sense of power and a sense of belonging. Participants are able to connect with each other and provide support and skills to deal with the day-to-day issues of raising a child with disabilities.

Leptospirosis occurring in two children after fresh water immersion

Leptospirosis is relatively uncommon in children. Two cases of severe leptospirosis occurred in teenaged boys who shared a common exposure via immersion in fresh water. While both patients had laboratory-confirmed leptospirosis, their symptoms differed in many respects.

Child's stress hormone levels correlate with mother's socioeconomic status and depressive state

BACKGROUND

Individuals with lower socioeconomic status report greater exposure to stressful life events and a greater impact of these events on their lives than individuals with higher socioeconomic status, and this relationship between socioeconomic status and health begins at the earliest stages of life. To extend on these results, we performed a psychoneuroendocrine study of 217 children and 139 mothers.

METHODS

Salivary cortisol levels and cognitive function were assessed in children, and a semistructured phone interview measuring symptoms of stress and depression was conducted with their mothers.

RESULTS

Children with low socioeconomic status present significantly higher salivary cortisol levels than children with high socioeconomic status, and this socioeconomic status effect emerges as early as age 6. We also report that a child's cortisol level is significantly correlated with his or her mother's extent of depressive symptomatology.

CONCLUSIONS

These results offer a neurobiological determinant to the well-known association between socioeconomic status and health that begins early in life.

Sex pheromone of orange wheat blossom midge, Sitodiplosis mosellana

Pheromone extract of the female orange wheat blossom midge, Sitodiplosis mosellana (Géhin) (SM) (Diptera: Cecidomyiidae), was analyzed by coupled gas chromatographic-electroantennographic detection (GC-EAD) and GC-mass spectrometry (MS), employing fused silica columns coated with DB-5, DB-210, DB-23 or SP-1000. These analyses revealed a single, EAD-active candidate pheromone which was identified as 2,7-nonanediyl dibutyrate. In experiments in wheat fields in Saskatchewan, traps baited with (2S,7S)-2,7-nonanediyl dibutyrate attracted significant numbers of male SM. The presence of other stereoisomers did not adversely affect trap captures. Facile synthesis of stereoisomeric 2,7-nonanediyl dibutyrate will facilitate the development of pheromone-based monitoring or even control of SM populations.

Is expressed emotion cause or effect in the mothers of schizophrenic young adults?

The purpose of this study was to determine the most likely direction of influence between the symptom severity in schizophrenic young adults and the expressed emotion (EE) of their mothers. Specifically, the stability and cross-lagged effects of mothers' critical comments (CC) or emotional overinvolvement (EOI) and the severity of four symptom clusters were examined. Twenty-eight patients and their mothers were interviewed three times at 9 month intervals. Data were subjected to a form of structural equation modeling: cross-lagged panel analysis. Results suggest that maternal CCs and EOI both tend to be influenced by the patient's total symptom severity and are influenced significantly by negative symptoms, but not by positive symptoms. Also, the more severe the hostile-uncooperative symptoms in the patient, the more critical the mothers become over time. However, the greater the mother's EOI at time 1, the less severe the patient's hostile-uncooperative symptoms at time 3. The usual implication of the association between high EE and relapse, which was also found in this sample, is that high EE causes symptom exacerbation. The results of the current study suggest that CCs and EOI coded from the CFI do not reflect a noxious environment: rather, they appear to be more effect than cause.

Continuous performance test differences among schizophrenic out-patients living in high and low expressed emotion environments

BACKGROUND

High expressed emotion (EE) in families reliably predicts relapse in schizophrenia leading to the assumption that high EE stresses patients and is the cause of relapse. Attempts at validating the stressful properties of high EE using autonomic skin conductance measures have been inconclusive. Since memory loaded vigilance tasks are sensitive to stress, we used a memory loaded version of the Continuous Performance Test (CPT) to see if test performance would change in the presence and absence of high or low EE relatives. If high EE was stressful, performance should decline in their presence of high EE relatives. If low EE was protective against stress performance should improve in the presence of low EE relatives.

METHODS

The CPT was administered to 41 schizophrenic and 51 normal control participants. CPT testing was conducted in the absence, then presence, then absence of high or low EE relatives.

RESULTS

Control participants had significantly greater CPT scores than schizophrenic participants; there was no effect of the relative's presence or absence on CPT performance for either the high or low EE group. Schizophrenic participants from high EE homes demonstrated significantly better, rather than worse, CPT scores than those in low EE homes.

CONCLUSIONS

These findings fail to support the notion of high EE as stressor, but show that high EE and low EE patient groups perform a vigilance task significantly differently. We propose that patients from low EE groups may be underaroused relative to their high EE counterparts and that this underarousal leads to less than optimal performance on the CPT.

Transforming negative work cultures: a practical strategy

At a time of unprecedented turbulence and challenge for healthcare organizations, maintaining healthy work environments is of paramount importance. Such environments support the day-to-day work of an organization and link its mission to customer service strategies and goals. We describe an unhealthy work culture and outline a practical approach that healthcare managers and clinical leaders can use to facilitate and sustain cultural transformation. The model is built on the core principles of ownership and investment in service outcomes as well as the life of the organization.

[A new vacuum extraction system with a ball joint and detachment warning--in vitro studies and clinical use]

BACKGROUND

The vacuum extractor is used in about 5% of deliveries. It is associated with a lower maternal morbidity than is forceps extraction. On the other hand, cephalhematomas, hyperbilirubinemia and cerebral hemorrhages in the baby are observed more frequently. The sudden detachment of the vacuum extractor with appreciable fluctuations in intracranial pressure in the baby is especially dangerous. In order to improve the conventional Malmström system, we have developed a new vacuum extractor and investigated its handling in vitro and in clinical application.

PATIENTS AND METHODS

The essential constructional principle of the new vacuum extractor consists in a pivot lowered by ball bearings and a volume reduction of one third. Moreover, in two-chamber vacuum it is possible to give a warning of sudden detachment. The possible tractional force in kiloponds was determined at various angles (0 degree, 15 degrees, 30 degrees und 45 degrees) comparing the Malmström extractor with the new one and two-chamber system in a standardized apparatus. In addition, the new vacuum extractor was also used clinically in 43 women; besides the obstetric parameters, the handling was also appraised.

RESULTS

In the in-vitro experiments, a distinct decrease of the possible tractional force with increasing angles was shown for the Malmström extractor (0 degree--15.7 kp, 15 degrees--12.7 kp, 30 degrees--8.6 kp, 45 degrees--7.3 kp). The values for the new one-chamber system were significantly greater from a tractional angle of 15 degrees (0 degree--15.6 kp, 15 degrees--14.4 kp, 30 degrees--14.0 kp, 45 degrees--13.8). The clinical application of the new vacuum system was unproblematic and confirmed the feasibility of good traction. A very much smaller caput succedaneum was found in the baby. Especially in the training situation, the warning system enables a good surveillance before sudden detachment, but reduces the possible tractional force.

CONCLUSIONS

The new vacuum system appears to enable the vaginal surgical delivery to be improved compared to the conventional Malmström extractor. After these promising approaches, a multicenter study was commenced in order to enable better evaluation of their clinical significance.

Evaluation of a standard breast tangent technique: a dose-volume analysis of tangential irradiation using three-dimensional tools

PURPOSE

A thorough dose-volume analysis of a standard tangential radiation technique has not been published. We evaluated the adequacy of a tangential radiation technique in delivering dose to the breast and regional lymphatics, as well as dose delivered to underlying critical structures.

METHODS AND MATERIALS

Treatment plans of 25 consecutive women with breast cancer undergoing lumpectomy and adjuvant breast radiotherapy were studied. Patients underwent two-dimensional (2D) treatment planning followed by treatment with standard breast tangents. These 2D plans were reconstructed without modification on our three-dimensional treatment planning system and analyzed with regard to dose-volume parameters.

RESULTS

Adequate coverage of the breast (defined as 95% of the target receiving at least 95% of the prescribed dose) was achieved in 16 of 25 patients, with all patients having at least 85% of the breast volume treated to 95% of the prescribed dose. Only 1 patient (4%) had adequate coverage of the Level I axilla, and no patient had adequate coverage of the Level II axilla, Level III axilla, or the internal mammary lymph nodes.

CONCLUSION

Three-dimensional treatment planning is superior in quantification of the dose received by the breast, regional lymphatics, and critical structures. The standard breast tangent technique delivers an adequate dose to the breast but does not therapeutically treat the regional lymph nodes in the majority of patients. If coverage of the axilla or internal mammary lymph nodes is desired, alternate beam arrangements or treatment fields will be necessary.

Lives in many hands: the medical landscape in Lancashire, 1700-1820

Medical historians over the last two decades have provided a basic overview of the development of the medical market-place, doctoring, diagnosis and treatment, doctor-patient relationships, and the nature and longevity of alternative medical practices. They have suggested that doctors were almost always the last port of call for most families confronting everyday illness, either because of cost, availability, or preference in the light of the limitations of medical diagnosis and treatment. Equally, it has been suggested that self-medication was common among middling and other families in the past, that “old wives” and irregular practitioners had a considerable longevity in the medical patchwork, and that “quackery” exploded in urban areas in particular during the later eighteenth century. The struggle by doctors to distance themselves both from their own patients (through new medical language and forms of diagnosis) and from other parts of the calling, such as apothecaries, has been well documented. So has the long-running conflict, in the spheres of diagnosis and treatment, between established medical theory on the one hand and empiricism on the other.

Electromechanical alterations in the cerebrovasculature of stroke-prone rats

BACKGROUND AND PURPOSE

Cerebrovascular pressure-dependent constriction (PDC) is associated with smooth muscle (SM) depolarization and Ca(2+) influx through voltage-gated channels. We studied the alterations in electromechanical contraction in the middle cerebral arteries (MCAs) of stroke-prone Wistar-Kyoto spontaneously hypertensive rats (SHRsp) in relation to the stroke-related loss of PDC.

METHODS

Constriction to pressure, elevated [K(+)](o) and/or [Ca(2+)](o), and SM membrane potentials (E(m)) were measured in isolated pressurized MCAs of SHRsp and stroke-resistant SHR.

RESULTS

MCAs of SHRsp exhibited an age-related decrease in PDC before hemorrhagic stroke and a loss of PDC after stroke. At 100 mm Hg, the MCAs of poststroke SHRsp maintained partial constriction that was not altered with pressure but was inhibited by nifedipine (1 micromol/L). The MCAs of poststroke SHRsp constricted to vasopressin (0.17 micromol/L) but not to elevated [K(+)](o). When pressure was reduced from 100 to 0 mm Hg, the MCAs from young prestroke SHRsp exhibited SM hyperpolarization (-38 to -46 mV), whereas those of poststroke SHRsp maintained a constant, depolarized E(m) (-34 mV). Alterations in E(m) with varying [K(+)](o) suggested that there was a decrease in SM K(+) conductance in the MCAs of poststroke SHRsp.

CONCLUSIONS

The observation that the MCAs of poststroke SHRsp depolarize but do not constrict to elevated [K(+)](o) suggests the presence of dysfunctional voltage-gated Ca(2+) channels. The inability to alter E(m) with pressure or to constrict to depolarization could partially contribute to the loss of PDC in the MCAs of poststroke SHRsp.