Case Report: Initial Successful Treatment of Migraine and Irritable Bowel Syndrome With a Low-FODMAP Diet

OBJECTIVE

Migraine and irritable bowel syndrome (IBS) can be difficult-to-treat comorbidities that may be driven by underlying gut-brain axis dysfunction. This report describes utilization of a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet (LFD) in a patient with refractory migraine and co-occurring IBS.

METHODS

After unremarkable physical and neurological examinations, a 57-year-old woman with IBS and chronic migraine was started on a LFD under the guidance of a registered dietician. Psychometrically validated surveys administered at baseline and initial follow-up assessed patient-reported outcomes related to migraine and IBS symptoms.

RESULTS

At baseline, the patient reported 80/90 migraine days with average pain of 8/10, a Migraine Disability Assessment (MIDAS) score of 33, and Headache Impact Test-6 (HIT-6) score of 64, the latter 2 scores indicating severe disability. Baseline IBS symptom severity was noted at 9/10. Within 1 week on a LFD, the patient's IBS symptoms and migraines improved in both frequency and intensity of episodes. After 5 weeks on a LFD elimination, the patient's clinical improvement continued and she reported significant reduction in migraines, with average pain of 1/10 and IBS severity of 3/10. The patient also improved from severe to minimal levels of disability on validated measures (MIDAS, HIT-6, and IBS Patient Global Impression of Change).

CONCLUSION

This is the first case report detailing successful initial treatment of migraine and co-occurring IBS utilizing a dietician-guided LFD. There are a number of important reasons for potential improvement in these gut-brain axis disorders which are reviewed as well as an implication for long-term management and food reintroduction. Larger, randomized trials evaluating a LFD in diverse individuals with migraine and co-occurring IBS are warranted to help confirm these results.

Detoxification Enhanced Lifestyle Intervention Targeting Endotoxemia (DELITE) in the Setting of Obesity and Pain: Results of a Pilot Group Intervention

BACKGROUND

Obesity is a complex multifactorial disorder affecting a growing proportion of the population. While therapeutic lifestyle change (TLC) is foundational, results of interventional programs are often inconsistent. Factors related to systemic inflammation, toxin load and endotoxemia have been postulated to play a contributory role. This pilot study sought to evaluate the role of TLC with enhanced laboratory evaluation and interventions to address these emerging therapeutic targets.

METHODS

Twelve participants with a body mass index (BMI) greater than 30 (or 27 with metabolic co-morbidities) were recruited from an outpatient clinic for participation with a primary outcome of pre/post changes in body composition. Participants completed a 12-week program involving weekly group and individualized dietary, exercise, and behavioral support, supplemented with a commercial, 30-day dietary detoxification intervention and ongoing nutritional counseling. All participants completed baseline and post-intervention evaluation including metabolic, toxin load, endotoxin, body composition and functional fitness profiles.

RESULTS

After 12-weeks, participants as a group significantly improved body composition parameters including BMI, body fat, fat mass, and waist and hip circumference (P < .01). Significant improvement in several secondary outcomes including levels of lipopolysaccharide, zonulin and leptin were noted. Additionally, results demonstrate substantial improvements in pain, pain interference and functional fitness. Upon completion, all participants rated the program favorably with a high likelihood of continuing or recommending participation to others.

CONCLUSIONS

Obesity remains a challenging and often refractory clinical scenario with emerging evidence indicating the potential role of systemic inflammation, toxin load and endotoxemia. A group therapeutic lifestyle change program enhanced with a detoxification component is feasible and may provide a promising intervention for achieving weight loss while also addressing functional and pain related co-morbidities. Future randomized trials evaluating the components of such a program are needed to better delineate the role of specific interventions in the complex setting of obesity.

Living kidney donor follow-up: state-of-the-art and future directions, conference summary and recommendations

In light of continued uncertainty regarding postkidney donation medical, psychosocial and socioeconomic outcomes for traditional living donors and especially for donors meeting more relaxed acceptance criteria, a meeting was held in September 2010 to (1) review limitations of existing data on outcomes of living kidney donors; (2) assess and define the need for long-term follow-up of living kidney donors; (3) identify the potential system requirements, infrastructure and costs of long-term follow-up for living kidney donor outcomes in the United States and (4) explore practical options for future development and funding of United States living kidney donor data collection, metrics and endpoints. Conference participants included prior kidney donors, physicians, surgeons, medical ethicists, social scientists, donor coordinators, social workers, independent donor advocates and representatives of payer organizations and the federal government. The findings and recommendations generated at this meeting are presented.

Appraisal of sessional EEG features as a correlate of clinical changes in an rTMS treatment of depression

Previous findings on electrophysiological features related to depression predict that these correlate with clinical assessment, and potentially act as proxy measures of state changes. We investigated selected electrophysiological features to evaluate their utility as proxies for clinical ratings and in prediction of treatment outcome. Using typical EEG data from an repetitive transcranial magnetic stimulation (rTMS) treatment regime, we analyzed individual alpha power and frequency, and asymmetry index from 39 patients with treatment resistant depression. The prognostic utility of these features was assessed in terms of group identification, correlation with clinical rating, or association with the time course of treatment. There was no significant group difference in asymmetry between depression patients and normal and clinical controls. Background alpha was significantly less in depression patients than controls, with the schizophrenia group midway between. There was no significant group change in asymmetry index or background alpha activity with treatment. There was a weak effect of rTMS over each session on alpha power and on asymmetry, but in the opposite direction to predictions. There was weak evidence of predicted correlation between asymmetry index change and clinical rating change, as well as in final scores that was opposite to predictions. Finally there was no strong evidence that either feature fitted a linear or more complex model of daily treatment. In conclusion, the findings are not sufficient, under our current clinical treatment regime, to support the use of background alpha activity or frontal asymmetry as proxies for clinical assessment. Several findings, however, provide support for further research in this direction.

When is pancreatitis considered to be of biliary origin and what are the implications for management?

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.

Laparoscopy and laparoscopic ultrasound in the evaluation of pancreatic and periampullary tumours

BACKGROUND AND AIMS

The pre-operative determination of resectability of pancreatic and peri-ampullary neoplasia assists the selection of patients for surgical or non-surgical treatment. This study investigated whether the addition of laparoscopy with laparoscopic ultrasound to dual-phase helical CT could improve the accuracy of assessment of resectability.

PATIENTS AND METHODS

Prospective study of 305 patients referred to a single unit for consideration of pancreatic resection who underwent dual-phase helical CT scanning +/- laparoscopy with laparoscopic ultrasound. Data were collected on patient demographics, CT findings, assessment of operability, laparoscopic assessment (LA), surgical procedures and histology.

RESULTS

LA was undertaken in 239/305 patients, 190 of whom were considered CT resectable, and 49 CT unresectable. Of the 190 CT resectable patients, LA correctly identified unresectability in 28 (15%: metastases in 15; vascular encasement in 6; anaesthesia for laparoscopy found 7 unfit for major resection) and incorrectly in 2 (vascular encasement), but did not identify unresectability in 33; LA correctly confirmed resectability in the remainder (prediction improved, chi(2) = 9.73, p < 0.01). Of the 49 CT unresectable patients, LA correctly identified resectability in 4, and incorrectly in 12, and correctly identified unresectability in the remaining 33. Sixty-six of the 305 patients did not undergo LA, of whom 23 underwent resection.

CONCLUSION

When added to dual-phase helical CT, laparoscopy with laparoscopic ultrasound provides valuable information that significantly improves the selection of patients for surgical or non-surgical treatment.

Major resection for chronic pancreatitis in patients with vascular involvement is associated with increased postoperative mortality

Background

The aim was to evaluate the outcome of major resection for chronic pancreatitis in patients with and without vascular involvement.

Methods

Of 250 patients with severe chronic pancreatitis referred between 1996 and 2003, 112 underwent pancreatic resection. The outcome of 17 patients (15·2 per cent) who had major vascular involvement was compared with that of patients without vascular involvement.

Results

The 95 patients without vascular involvement had resections comprising Beger's operation (39 patients), Kausch–Whipple pancreatoduodenectomy (28), total pancreatectomy (25) and left pancreatectomy (three). Twenty-five major vessels were involved in the remaining 17 patients. One or more major veins were occluded and/or compressed producing generalized or segmental portal hypertension, and three patients also had major arterial involvement. Surgery in these patients comprised Beger's operation (eight), total pancreatectomy (five), Kausch–Whipple pancreatoduodenectomy (two) and left pancreatectomy (two). Perioperative mortality rates were significantly different between the groups (two of 95 versus three of 17 respectively; P = 0·024). There were similar and significant improvements in long-term outcomes in both groups.

Conclusion

Resection for severe chronic pancreatitis in patients with vascular complications is hazardous and is associated with an increased mortality rate. Vascular assessment should be included in the routine follow-up of patients with chronic pancreatitis, to enable early identification of those likely to develop vascular involvement and prompt surgical intervention.

T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis

BACKGROUND

Non-alcoholic duct destructive chronic pancreatitis is a rare entity with specific pathological features. The majority of the patients are from Japan. We report a case with involvement of the distal bile duct, the gallbladder, the duodenum and the ampulla, and present a review of patients from Europe and the USA since 1997.

CASE PRESENTATION

A 56-year-old man presented with a 3-month history of mild acute pancreatitis and obstructive jaundice, followed by increasing weight loss, lethargy and epigastric pain. CT showed a mass in the head of the pancreas. ERCP demonstrated a smooth stricture of the intra-pancreatic main bile duct and an irregular, incomplete, stricture in the main pancreatic duct. A pancreatic cancer could not be reliably excluded, and, therefore, he underwent a pylorus-preserving Kausch-Whipple's pancreatoduodenectomy.

RESULTS

Histopathology showed typical peri-ductal T cell-rich lymphoplasmacellular and eosinophilic infiltration of the pancreas, with involvement of the distal bile duct but, also, unusual inflammatory infiltration of the gallbladder, the duodenum and the ampulla.

CONCLUSION

The inflammatory process in non-alcoholic duct-destructive chronic pancreatitis can affect the entire pancreato-biliary region and mimics pancreatic cancer. Currently, there are no definitive criteria for pre-operative diagnosis, so it is very difficult for one to avoid resection.

Double resection for patients with pancreatic cancer and a second primary renal cell cancer

BACKGROUND

Reports of synchronous or metachronous double kidney-pancreas cancers are very rare.

METHODS

We present 2 patients with renal cell carcinoma and synchronous (1 patient) or metachronous (1 patient) primary pancreatic ductal adenocarcinoma. The patients underwent resection for both cancer types with a worthwhile outcome.

RESULTS

The appearance of different primaries in an individual may indicate a genetic predisposition to different neoplasms. The study of double primary cancers is important because it might provide understanding of a shared genetic basis of different solid tumors.

CONCLUSIONS

The association between these two cancers demands more detailed epidemiological and molecular investigation. From a clinical viewpoint a resectional policy is recommended.

Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy

BACKGROUND

The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis.

METHODS

Sixty-four patients who underwent pancreatic necrosectomy between 1996 and 2002 were studied.

RESULTS

The median age was 60.5 (95 per cent confidence interval (c.i.) 57 to 64) years and 40 patients (62.5 per cent) were tertiary referrals. The initial median Acute Physiology And Chronic Health Evaluation (APACHE) II score was 9 (95 per cent c.i. 7.9 to 10.1) and there were 21 deaths (32.8 per cent). Twenty-eight patients (43.8 per cent) underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and the remainder had open pancreatic necrosectomy (OPN); 44 (72.1 per cent) of 61 patients had infected pancreatic necrosis at the time of the first procedure. Seven patients who underwent MIRP died compared with 14 after OPN (P = 0.240). Patients who died were older than those who survived, with higher APACHE II scores at presentation, and before and after surgery (P = 0.001). Survivors had significantly longer times to surgery than those who died (P = 0.038). All 21 patients who died required intensive care compared with 26 of 43 survivors (P < 0.001). Thirty of 36 patients who had the OPN procedure required intensive care compared with only 17 of 28 patients who had MIRP (P = 0.042). Logistic regression analysis showed that only postoperative APACHE II score was an independent predictor of increased mortality (P = 0.031).

CONCLUSION

Advanced age and increasing APACHE II score, and a need for postoperative intensive care, were the most important predictors of outcome after pancreatic necrosectomy.

Initial results with a minimally invasive technique of pancreatic necrosectomy

Background

The aim of the study was to evaluate the initial results with a new technique of minimally invasive pancreatic necrosectomy (MIPN).

Methods

A retrospective audit was carried out of pancreatic necrosectomies performed on one unit from October 1996. Patients were divided into two groups: those admitted before November 1998 who underwent a conventional open necrosectomy and those admitted after this date who were considered for treatment with MIPN.

Results

Thirty-one patients underwent pancreatic necrosectomy, of which 20 cases were tertiary referrals. Thirteen patients (median age 51 (range 33–77) years; ten men, three women) admitted before November 1998 underwent a conventional open technique; seven of these patients died. Since then, 18 patients (median age 59 (range 33–74) years; ten women, eight men) have undergone necrosectomy, 12 by MIPN (median of 3 (range 1–6) procedures) and six by an open technique. Reasons for using an open technique included a left renal adenocarcinoma (one patient), poor access route (three patients) and failure to insert a guidewire under computed tomographic control (two patients). There were two deaths during this later period (P &lt; 0·05, Fisher's exact test in comparison with the earlier time period). In patients who were discharged there was no difference in length of stay in the intensive treatment unit (median 5 (range 0–24) versus 5 (range 0–84) days) or in-hospital stay (median 66 (range 29–159) versus 75 (range 31–202) days) between the two time periods.

Conclusion

A minimally invasive approach provides a promising alternative to open pancreatic necrosectomy.

Management of necrotizing pancreatitis

Infection complicating pancreatic necrosis leads to persisting sepsis, multiple organ dysfunction syndrome and accounts for about half the deaths that occur following acute pancreatitis. Severe cases due to gallstones require urgent endoscopic sphincterotomy. Patients with pancreatic necrosis should be followed with serial contrast enhanced computed tomography (CE-CT) and if infection is suspected fine needle aspiration of the necrotic area for bacteriology (FNAB) should be undertaken. Treatment of sterile necrosis should initially be non-operative. In the presence of infection necrosectomy is indicated. Although traditionally this has been by open surgery, minimally invasive procedures are a promising new alternative. There are many unresolved issues in the management of pancreatic necrosis. These include, the use of antibiotic prophylaxis, the precise indications for and frequency of repeat CE-CT and FNAB, and the role of enteral feeding.

COPD and exercise

Optimal function and symptom control are primary management objectives for persons with chronic obstructive pulmonary disease (COPD). Exercise plays an important role in meeting these challenging treatment goals. This article presents factors that limit endurance for persons with COPD, broad exercise goals, elements of appropriate exercise prescription, and various options that lead to successful outcomes.

Role of chest CT scanning in the management of patients presenting with head and neck cancer

BACKGROUND

The detection of synchronous tumors, whether they be second primaries or distant metastases, in patients with head and neck carcinoma drastically affects prognosis and may alter management. Computerized tomographic (CT) scanning of the chest is an effective screening investigation in this group of patients, both in the detection of synchronous second primary tumors, the incidence of which in this study is 15%, and for accurate staging of metastatic pulmonary disease. The incidence of synchronous tumors in patients who are initially seen with head and neck squamous cell carcinoma (HNSCC) has been reported in large retrospective studies as being between 1% and 3%. These may be either second primary tumors or metastases, and the lung is the commonest site for both.

METHODS

Eighty-one head and neck cancer patients (67 primary and 14 secondary referrals) treated at the Royal Liverpool University Hospital between 1994 and 1996 underwent CT scanning of the chest with ultrasound of the liver as part of their routine staging. The results were compared with standard chest x-rays also performed in each patient.

RESULTS

Fourteen patients had pulmonary tumors detected on the chest CT scan. In 67 patients, the scan was negative. Patients with negative scans tended not to have neck node metastases (64%), whereas patients with positive scans were much more likely to have neck node metastases with negative necks present in only 36% of patients. Where multivariate analysis was carried out, there was a correlation between neck node metastases and positive CT scans of the chest (estimate = 0.5755, standard error = 0.3066, chi2(1) = 6.73, p .047). The sensitivity of chest x-ray compared with CT scan was only 21 % and the specificity 99%. The positive predictive value of a chest x-ray was 75% and the negative predictive value 86%. Intra-abdominal lesions were detected in two patients, one in the liver and one in the adrenal gland. In the latter patient, this was an isolated lesion, but in the former, the chest scan was also positive. In the 67 patients, who were initially seen at the Royal Liverpool Hospital (primary referrals), the incidence of synchronous tumors was 15%.

CONCLUSIONS

Synchronous tumors, whether they be second primary tumors or distant metastases, are more common in patients initially seen with head and neck cancer than is realized, their incidence being significantly higher in those patients with cervical metastases. Computerized tomographic scanning of the chest is a more effective screening investigation than chest x-ray in this group of patients and is now used routinely in our department prior to undertaking major head and neck surgery.

Breaking self-tolerance in nonobese diabetic mice

Unresponsiveness to self is maintained through two mechanisms of immune regulation: thymic-negative selection and peripheral tolerance. Although thymic-negative selection is a major mechanism to eliminate self-reactive T cells, normal mice have readily detectable populations of T cells reactive to self-proteins but do not exhibit autoimmune responses. It has been postulated that autoimmune disease results from breakdown or loss of peripheral tolerance. We present data that demonstrate that peripheral tolerance or unresponsiveness to self can be broken in nonobese diabetic (NOD) mice. Immunization of NOD mice (but not of conventional mice) with self-peptides caused an immune response to self-peptide with resultant autoproliferation of peripheral lymphocytes. Autoproliferation of self-reactive T cells in NOD mice resulted from the recognition and proliferation of the activated T cells to endogenously processed and presented self-antigens. This loss of self-tolerance demonstrated in vitro may well be the basis of NOD autoimmune disease in vivo.

A longitudinal study of maternal depression and preschool children's mental health

The purpose of this longitudinal study was to examine the relationship between maternal depression and preschool children's mental health in a community sample. Cohort 1 (n = 97) consisted of mothers and children followed from 2 to 3 years of age. Cohort 2 (n = 97) consisted of mothers and children followed from 3 to 4 years of age. Mothers completed a self-report measure of depression twice during 1 year. The children's day care providers/nursery school teachers completed two instruments measuring the children's social competence and behavior problems at the end of the year. Maternal depression was significantly related to lower social competence and more behavior problems in the children. Although there were no significant mean differences in children's mental health scores by gender, boys of more depressed mothers were more likely to have poorer social competence and more behavior problems than girls. Item analyses suggest that the boys' behaviors may be particularly aversive for depressed mothers, increasing the likelihood that these mothers will respond to and reinforce their sons' difficult behaviors.

Intraluminal duodenal diverticulum causing recurrent pancreatitis: treatment by endoscopic incision

Intraluminal duodenal diverticulum is a recognised but rare cause of acute pancreatitis. This patient had three attacks of pancreatitis, each requiring a stay in hospital, within a four month period. The apex of the diverticulum was incised endoscopically, whereupon peas and food debris gushed from the incision site. The patient has had no further symptoms in the 12 months since the endoscopic procedure.

What does the NCATS (Nursing Child Assessment Teaching Scale) measure?

The purpose of this study was to examine what aspects of the mother-child relationship are measured by the Nursing Child Assessment Teaching Scale (NCATS). A racially heterogeneous sample of 128 mothers completed questionnaires measuring maternal depression, parenting self-efficacy, knowledge of developmental and parenting principles, and perceived difficult toddler temperament. Mothers and children were also videotaped during home visits while completing two teaching tasks that were later scored using NCATS. NCATS Parent subscale scores were significantly related to maternal knowledge and education but unrelated to depression and self-efficacy. Child subscale scores were unrelated to all of the study variables, including perceived difficult temperament. Significant differences were noted among African-American, Hispanic, and white mothers. The findings suggest that the NCATS taps cognitive factors more reliably than affective factors underlying the mother-child relationship and the cognitive factors may be culturally biased.

Intestinal ischemia: treatment by peritoneal lavage with oxygenated perfluorochemical

Though the delivery of elemental oxygen to tissues ravaged by anaerobic infection may be useful, little data exists that suggests that such therapy may benefit ischemic tissue. We report the development of a model to test the question that peritoneal lavage with an oxygen containing solution may favorably influence occlusive intestinal ischemia. Adult Sprague-Dawley rats with Nembutal (sodium pentobarbital) anesthesia underwent midline laparotomy; a microvascular clamp was applied to the superior mesenteric artery (SMA); and an inflow and outflow lavage catheter was placed. Treatment groups included control rats undergoing SMA occlusion only without lavage, rats lavaged with albumin during SMA occlusion (medium control), and rats lavaged during SMA occlusion with oxygenated perfluorochemical FC-47 emulsified in albumin (O2-FC-47). The increase in serum L-lactate following occlusion was used as an index of intestinal injury whether the perfusate was maintained at room temperature (28 degrees C) or body temperature (37 degrees C). Beginning with time O, which corresponded to the time of unclamping, subsequent samples were collected at 15, 30, and 60 minutes after a 30-minute SMA occlusion. Sequential lactates in 13 control rats were 4.18, 4.10, 3.88, and 4.52 mmol/L. Albumin lavaged animals had values at 28 degrees C of 2.23, 1.35, 1.8, and 2.44 mmol/L and values at 37 degrees C of 2.22, 1.40, 2.07, and 3.21 mmol/L, respectively. With O2-FC-47 lavage the respective lactates were 1.89, 1.09, 1.32, and 1.44 mmol/L at 28 degrees C and 2.14, 2.19, 2.50, and 2.1 mmol/L at 37 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychiatric disorder among boys with Duchenne muscular dystrophy

The prevalence of psychiatric disorder in 23 boys with Duchenne muscular dystrophy was assessed and compared to a matched control group. Dysthymic disorder and major depressive disorder occurred significantly more often among DMD boys than controls. Older boys with DMD were at greater risk of depressive disorder than younger boys. Possible aetiological factors and approaches to management are discussed.

Tag construction: structure and function in child discourse

A distinction has been drawn between tag questions which occur within the same temporally defined turn and those in a second turn by the same speaker. A TAG CONSTRUCTION has been defined as a MATRIX CLAUSE (any syntax) and a TAG FORM (reduced interrogative in elliptical constructions; or interrogative expression in stereotypical constructions) produced WITHIN THE SAME TURN. The discoursal functions of tag constructions include requests for information, agreement, permission, compliance, responsiveness and attention. Although stereotypical tag constructions emerge earlier in development than elliptical tag constructions, from the beginning stereotypical tag constructions perform the same discoursal functions as the grammatically more complex elliptical constructions as well as additional ones. Tag constructions are less effective than canonical questions in obtaining turn transfers. This relative ineffectiveness may be due to either the post-positioned clearance signal or the fact that the listener feels less compelled to respond when the speaker seems to have an expectation as to what the response to the request should be.

Complementary balance in the use of the interrogative form by nursery school dyads

Child partners were compared on their relative tendency to use the interrogative form in spontaneous dyadic verbal interactions. A given child's tendency to use the interrogative form more frequently than the other member of the dyad remained constant across partners. This relative stability in formulating utterances in interrogative form cannot be attributed to the child's producing more talk in general than the partner. The observed effect is explained as a type of conversational synchrony in which participants achieve a complementary balance rather than congruence. It was concluded that the interrogative form is a linguistic means for child peers to establish cooperation as well as controlling kinds of relationships during an ongoing interaction.

The education of physically handicapped children in normal schools

This paper is based on our experience in the Central Remedial Clinic over a number of years that physically handicapped children do not in general do well in ordinary schools. An attempt is made to delineate some of the problems that may confront a handicapped child of generally average intelligence who attends a normal school. These problems are associated with the following conditions: specific learning difficulties, emotional problems, poor school attendance, large classes, limitations in ordinary teacher training and lack of remedial teachers and other special staff. The need for early and continued psychological and educational assessments is emphasized, and it is suggested that most young physically handicapped children of average intelligence would benefit from starting in a special assessment unit, to ensure as far as possible, correct school placement. This view is not currently held by a number of educational authorities who generally advise that physically handicapped children should go to ordinary schools if possible. We feel that this advice is not always in the best interests of the child. There is need for continuing friendly and informal communications between parents and members of the special school team.