The compensatory reserve index predicts recurrent shock in patients with severe dengue

BACKGROUND

Dengue shock syndrome (DSS) is one of the major clinical phenotypes of severe dengue. It is defined by significant plasma leak, leading to intravascular volume depletion and eventually cardiovascular collapse. The compensatory reserve Index (CRI) is a new physiological parameter, derived from feature analysis of the pulse arterial waveform that tracks real-time changes in central volume. We investigated the utility of CRI to predict recurrent shock in severe dengue patients admitted to the ICU.

METHODS

We performed a prospective observational study in the pediatric and adult intensive care units at the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. Patients were monitored with hourly clinical parameters and vital signs, in addition to continuous recording of the arterial waveform using pulse oximetry. The waveform data was wirelessly transmitted to a laptop where it was synchronized with the patient's clinical data.

RESULTS

One hundred three patients with suspected severe dengue were recruited to this study. Sixty-three patients had the minimum required dataset for analysis. Median age was 11 years (IQR 8-14 years). CRI had a negative correlation with heart rate and moderate negative association with blood pressure. CRI was found to predict recurrent shock within 12 h of being measured (OR 2.24, 95% CI 1.54-3.26), P < 0.001). The median duration from CRI measurement to the first recurrent shock was 5.4 h (IQR 2.9-6.8). A CRI cutoff of 0.4 provided the best combination of sensitivity and specificity for predicting recurrent shock (0.66 [95% CI 0.47-0.85] and 0.86 [95% CI 0.80-0.92] respectively).

CONCLUSION

CRI is a useful non-invasive method for monitoring intravascular volume status in patients with severe dengue.

Phenomenological Constraints on the Transport Properties of QCD Matter with Data-Driven Model Averaging

Using combined data from the Relativistic Heavy Ion and Large Hadron Colliders, we constrain the shear and bulk viscosities of quark-gluon plasma (QGP) at temperatures of ∼150-350  MeV. We use Bayesian inference to translate experimental and theoretical uncertainties into probabilistic constraints for the viscosities. With Bayesian model averaging we propagate an estimate of the model uncertainty generated by the transition from hydrodynamics to hadron transport in the plasma's final evolution stage, providing the most reliable phenomenological constraints to date on the QGP viscosities.

Low postnatal CRI values are associated with the need for ECMO in newborns with CDH

INTRODUCTION

Accurate, real-time technology is needed to predict which newborns with congenital diaphragmatic hernia (CDH) will require ECMO. The Compensatory Reserve Index (CRI) is a noninvasive monitoring technology that continuously trends an individual's capacity to compensate from normovolemia (CRI = 1) to decompensation (CRI = 0). We hypothesized that postnatal CRI values would be lower in CDH newborns that required ECMO than those who did not require ECMO.

METHODS

Newborns with a CDH were prospectively monitored with a CipherOx® CRI M1 device. We compared CRI values from delivery to ECMO (ECMO group) versus delivery to clinical stabilization (non-ECMO group).

RESULTS

Postnatal CRI values were available from 26 newborns. Eight underwent ECMO within 33 h of delivery, and median CRI prior to ECMO was 0.068 (IQR: 0.057, 0.078). Eighteen did not require ECMO. Median CRI from birth to 48 h was 0.112 (IQR: 0.082, 0.15). CRI values were significantly lower in newborns that required ECMO versus those who did not (p = 0.0035). Postnatal CRI had the highest AUC (0.85) compared to other prenatal prognostic measures.

CONCLUSION

Humans from newborns to adults share elemental features of the pulsatile waveform that are associated with progression to decompensation. CRI may be helpful when deciding when to initiate ECMO.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Diagnostic test.

Correction to: A systematic review of stakeholder views of selection methods for medical schools admission

Following publication of the original article [1], the author report typographical errors in the.

A systematic review of stakeholder views of selection methods for medical schools admission

BACKGROUND

The purpose of this paper is to systematically review the literature with respect to stakeholder views of selection methods for medical school admissions.

METHODS

An electronic search of nine databases was conducted between January 2000-July 2014. Two reviewers independently assessed all titles (n = 1017) and retained abstracts (n = 233) for relevance. Methodological quality of quantitative papers was assessed using the MERSQI instrument. The overall quality of evidence in this field was low. Evidence was synthesised in a narrative review.

RESULTS

Applicants support interviews, and multiple mini interviews (MMIs). There is emerging evidence that situational judgement tests (SJTs) and selection centres (SCs) are also well regarded, but aptitude tests less so. Selectors endorse the use of interviews in general and in particular MMIs judging them to be fair, relevant and appropriate, with emerging evidence of similarly positive reactions to SCs. Aptitude tests and academic records were valued in decisions of whom to call to interview. Medical students prefer interviews based selection to cognitive aptitude tests. They are unconvinced about the transparency and veracity of written applications. Perceptions of organisational justice, which describe views of fairness in organisational processes, appear to be highly influential on stakeholders' views of the acceptability of selection methods. In particular procedural justice (perceived fairness of selection tools in terms of job relevance and characteristics of the test) and distributive justice (perceived fairness of selection outcomes in terms of equal opportunity and equity), appear to be important considerations when deciding on acceptability of selection methods. There were significant gaps with respect to both key stakeholder groups and the range of selection tools assessed.

CONCLUSIONS

Notwithstanding the observed limitations in the quality of research in this field, there appears to be broad concordance of views on the various selection methods, across the diverse stakeholders groups. This review highlights the need for better standards, more appropriate methodologies and for broadening the scope of stakeholder research.

Development of a Non-invasive Cerebrovascular Status Algorithm to Estimate Cerebral Perfusion Pressure and Intracranial Pressure in a Porcine Model of Focal Brain Injury

Background

New tools for diagnosis, monitoring, and treatment of elevated intracranial pressure (ICP) or compromised cerebral perfusion pressure (CPP) are urgently needed to improve outcomes after brain injury. Previous success in applying advanced data analytics to build precision monitors based on large, noisy sensor datasets suggested applying the same approach to monitor cerebrovascular status. In these experiments, a new algorithm was developed to estimate ICP and CPP using the arterial pressure waveform.

Methods

Sixty-five porcine subjects were subjected to a focal brain injury to simulate a mass lesion with elevated ICP. The arterial pressure waveform and the measured ICP from these subjects during injury and treatment were then utilized to develop and calibrate an ICP and CPP estimation algorithm. These estimation algorithms were then subsequently evaluated on 14 new subjects.

Results

The root mean square difference between actual ICP and estimated ICP was 2.0961 mmHg. The root mean square difference between the actual CPP and the estimated CPP was 2.6828 mmHg.

Conclusion

A novel ICP or CPP monitor based on the arterial pressure signal produced a very close approximation to actual measured ICP and CPP and warrants further evaluation.

Noninvasive monitoring of physiologic compromise in acute appendicitis: New insight into an old disease

INTRODUCTION

Physiologic compromise in children with acute appendicitis has heretofore been difficult to measure. We hypothesized that the Compensatory Reserve Index (CRI), a novel adjunctive cardiovascular status indicator, would be low for children presenting with acute appendicitis in proportion to their physiological compromise, and that CRI would rise with fluid resuscitation and surgical management of their disease.

METHODS

Ninety-four children diagnosed with acute appendicitis were monitored with a CipherOx CRI™ M1 pulse oximeter (Flashback Technologies Inc., Boulder, CO). For clarity, CRI=1 indicates supine normovolemia, CRI=0 indicates hemodynamic decompensation (systolic blood pressure<80mmHg), and CRI values between 1 and 0 indicate the proportion of volume reserve remaining before collapse. Results are presented as counts with proportion (%), or mean with 95% confidence interval (CI).

RESULTS

Mean age was 11years old (95% CI: 10-12), and 49 (52%) of the children were male. Fifty-four (57%) had nonperforated appendicitis and 40 (43%) had perforated appendicitis. Mean initial CRI was significantly higher in those with nonperforated appendicitis compared to those with perforated appendicitis (0.57, 95% CI: 0.52-0.63 vs. 0.36, 95% CI: 0.29-0.43; P<0.001). The significant differences in mean CRI values between the two groups remained throughout the course of treatment, but lost its significance at 2h after surgery (0.63, 95% CI: 0.57-0.70 vs. 0.53, 95% CI: 0.46-0.61; P=0.05).

CONCLUSION

Low CRI values in children with perforated appendicitis are indicative of their lower reserve capacity owing to peritonitis and hypovolemia. CRI offers a real-time, noninvasive adjunctive tool to monitor tolerance to volume loss in children.

LEVEL OF EVIDENCE

Study of diagnostic test; Level of evidence: Level III.

State-of-the-art monitoring in treatment of dengue shock syndrome: a case series

BACKGROUND

Early recognition and treatment of circulatory volume loss is essential in the clinical management of dengue viral infection. We hypothesized that a novel computational algorithm, originally developed for noninvasive monitoring of blood loss in combat casualties, could: (1) indicate the central volume status of children with dengue during the early stages of "shock"; and (2) track fluid resuscitation status.

METHODS

Continuous noninvasive photoplethysmographic waveforms were collected over a 5-month period from three children of Thai ethnicity with clinical suspicion of dengue. Waveform data were processed by the algorithm to calculate each child's Compensatory Reserve Index, where 1 represents supine normovolemia and 0 represents the circulatory volume at which hemodynamic decompensation occurs. Values between 1 and 0 indicate the proportion of reserve remaining before hemodynamic decompensation.

RESULTS

This case report describes a 7-year-old Thai boy, another 7-year-old Thai boy, and a 9-year-old Thai boy who exhibited signs and symptoms of dengue shock syndrome; all the children had secondary dengue virus infections, documented by serology and reverse transcriptase polymerase chain reaction. The three boys experienced substantial plasma leakage demonstrated by pleural effusion index >25, ascites, and >20 % hemoconcentration. They received fluid administered intravenously; one received a blood transfusion. All three boys showed a significantly low initial Compensatory Reserve Index (≥0.20), indicating a clinical diagnosis of "near shock". Following 5 days with fluid resuscitation treatment, their Compensatory Reserve Index increased towards "normovolemia" (that is, Compensatory Reserve Index >0.75).

CONCLUSIONS

The results from these cases demonstrate a new variation in the diagnostic capability to manage patients with dengue shock syndrome. The findings shed new light on a method that can avoid possible adverse effects of shock by noninvasive measurement of a patient's compensatory reserve rather than standard vital signs or invasive diagnostic methods.

Comparison of compensatory reserve during lower-body negative pressure and hemorrhage in nonhuman primates

Compensatory reserve was measured in baboons (n = 13) during hemorrhage (Hem) and lower-body negative pressure (LBNP) using a machine-learning algorithm developed to estimate compensatory reserve by detecting reductions in central blood volume during LBNP. The algorithm calculates compensatory reserve index (CRI) from normovolemia (CRI = 1) to cardiovascular decompensation (CRI = 0). The hypothesis was that Hem and LBNP will elicit similar CRI values and that CRI would have higher specificity than stroke volume (SV) in predicting decompensation. Blood was removed in four steps: 6.25%, 12.5%, 18.75%, and 25% of total blood volume. Four weeks after Hem, the same animals were subjected to four levels of LBNP that was matched on the basis of their central venous pressure. Data (mean ± 95% confidence interval) indicate that CRI decreased (P < 0.001) from baseline during Hem (0.69 ± 0.10, 0.57 ± 0.09, 0.36 ± 0.10, 0.16 ± 0.08, and 0.08 ± 0.03) and LBNP (0.76 ± 0.05, 0.66 ± 0.08, 0.36 ± 0.13, 0.23 ± 0.11, and 0.14 ± 0.09). CRI was not different between Hem and LBNP (P = 0.20). Linear regression analysis between Hem CRI and LBNP CRI revealed a slope of 1.03 and a correlation coefficient of 0.96. CRI exhibited greater specificity than SV in both Hem (92.3 vs. 82.1) and LBNP (94.8 vs. 83.1) and greater ROC AUC in Hem (0.94 vs. 0.84) and LBNP (0.94 vs. 0.92). These data support the hypothesis that Hem and LBNP elicited the same CRI response, suggesting that measurement of compensatory reserve is superior to SV as a predictor of cardiovascular decompensation.

Compensatory Reserve for Early and Accurate Prediction of Hemodynamic Compromise: Case Studies for Clinical Utility in Acute Care and Physical Performance

BACKGROUND

Humans are able to compensate for significant loss of their circulating blood volume, allowing vital signs to remain relatively stable until compensatory mechanisms are overwhelmed. The authors present several clinical and performance case studies in an effort to demonstrate real-time measurements of an individual's reserve to compensate for acute changes in circulating blood volume. This measurement is referred to as the Compensatory Reserve Index (CRI).

METHODS

We identified seven clinical and two physical performance conditions relevant to military casualty and operational medicine as models of intravascular volume compromise. Retrospective analysis of photoplethysmogram (PPG) waveform features was used to calculate CRI, where 1 represents supine normovolemia and 0 represents hemodynamic decompensation.

RESULTS

All cases had CRI values suggestive of volume compromise (<0.6) not otherwise evident by heart rate and systolic blood pressure. CRI decreased with reduced central blood volume and increased with restored volume (e.g., fluid resuscitation).

CONCLUSION

The results from these case studies demonstrate that machine-learning techniques can be used to (1) identify a clinical or physiologic status of individuals through real-time measures of changes in PPG waveform features that result from compromise to circulating blood volume and (2) signal progression toward hemodynamic instability, with opportunity for early and effective intervention, well in advance of changes in traditional vital signs.

Respiratory pump contributes to increased physiological reserve for compensation during simulated haemorrhage

Intrathoracic pressure regulation (IPR) represents a therapy for increasing systemic circulation through the creation of negative intrathoracic pressure. We hypothesized that using this 'respiratory pump' effect would slow the diminution of the physiological reserve to compensate during progressive reductions in central blood volume. The compensatory reserve index (CRI) algorithm was used to measure the proportion (from 100 to 0%) of reserve capacity that remained to compensate for central volume loss before the onset of cardiovascular decompensation. Continuous analog recordings of arterial waveforms were extracted from data files of seven healthy volunteers. Subjects had previously participated in experiments designed to induce haemodynamic decompensation (presyncope) by progressive reduction in central blood volume using graded lower-body negative pressure. The lower-body negative pressure protocol was completed while breathing spontaneously through a standard medical face mask without (placebo) and with a resistance (approximately -7 cmH2O; active IPR) applied during inspiration. At the onset of presyncope in the placebo conditions, CRI was smaller than the CRI observed at the same time point in the active IPR conditions. The CRI at the onset of presyncope during active IPR (0.08 ± 0.01) was similar to the CRI at presyncope with placebo. Kaplan-Meier and log rank tests indicated that CRI survival curves were shifted to the right by active IPR. Optimizing the respiratory pump contributed a small but significant effect of increasing tolerance to progressive reductions in central blood volume by extending the compensatory reserve.

Exposure to life events as a risk factor for psychological problems in adults with intellectual disabilities: a longitudinal design

BACKGROUND

Several cross-sectional studies have shown an association between exposure to life events and psychological problems in adults with intellectual disability (ID). To establish life events as a risk factor, prospective designs are needed.

METHODS

Support staff informants provided data on the psychological problems of 68 adults with ID and their recent exposure to life events. Using data collected on the same sample 3.5 to 4 years earlier, prospective analysis of the relationships between life events exposure and psychological problems over time was explored.

RESULTS

Hierarchical linear regression analyses demonstrated a contribution of life events to the prediction of later psychological problems after controlling for earlier psychological problems. Exploratory analyses showed that the relationship between life events and psychological problems might be unidirectional, and non-spurious; remaining present once the impact of other correlates of psychological problems was controlled.

CONCLUSIONS

These data offer support for the status of life events (with a negative valence) as a risk factor for psychological problems in adults with ID. To establish life events as a causal risk factor, research is needed to examine the mechanisms via which life events have their impact on psychological well-being.

Estimation of individual-specific progression to impending cardiovascular instability using arterial waveforms

Trauma patients with “compensated” internal hemorrhage may not be identified with standard medical monitors until signs of shock appear, at which point it may be difficult or too late to pursue life-saving interventions. We tested the hypothesis that a novel machine-learning model called the compensatory reserve index (CRI) could differentiate tolerance to acute volume loss of individuals well in advance of changes in stroke volume (SV) or standard vital signs. Two hundred one healthy humans underwent progressive lower body negative pressure (LBNP) until the onset of hemodynamic instability (decompensation). Continuously measured photoplethysmogram signals were used to estimate SV and develop a model for estimating CRI. Validation of the CRI was tested on 101 subjects who were classified into two groups: low tolerance (LT; n = 33) and high tolerance (HT; n = 68) to LBNP (mean LBNP time: LT = 16.23 min vs. HT = 25.86 min). On an arbitrary scale of 1 to 0, the LT group CRI reached 0.6 at an average time of 5.27 ± 1.18 (95% confidence interval) min followed by 0.3 at 11.39 ± 1.14 min. In comparison, the HT group reached CRI of 0.6 at 7.62 ± 0.94 min followed by 0.3 at 15.35 ± 1.03 min. Changes in heart rate, blood pressure, and SV did not differentiate HT from LT groups. Machine modeling of the photoplethysmogram response to reduced central blood volume can accurately trend individual-specific progression to hemodynamic decompensation. These findings foretell early identification of blood loss, anticipating hemodynamic instability, and timely application of life-saving interventions.

Abstract P6-04-02: Profiling of BRCA1 Mutated Breast Tumours Using a Breast Cancer Specific Microarray To Identify a Profile of BRCAl-Deficiency

Background

The BRCA 1 tumour suppressor gene is mutated in a significant proportion of hereditary breast cancer cases. Additionally, downregulation of BRCA1 mRNA and protein expression is reported in approximately one third of sporadic breast cancers. BRCA1 is strongly implicated in the maintenance of genomic stability by its involvement in multiple cellular pathways including: DNA damage signalling, DNA repair, cell cycle regulation, protein ubiquitination, chromatin remodelling, transcriptional regulation and apoptosis. To date, gene expression profiling has identified: (1) at least five breast cancer subtypes and (2) that BRCA1 mutant tumours segregate with basal-like breast cancers. These studies also provide evidence that breast cancers with germline mutations in BRCA1 are different from non BRCA1-related tumours. The main aim of this study is to investigate the underlying biology of BRCA1-mutated breast cancer. Methods

Extensive gene expression profiling and data analysis were performed on a cohort of 70 FFPE (Formalin Fixed Paraffin Embedded) derived BRCA 1 mutated breast tumours and matched sporadic controls using the Almac Breast Cancer DSATM research tool. Functional analysis was performed with DAVID and METACORE. Validation of gene targets was performed by qRT-PCR and Western blotting. Results

A list of differentially expressed transcripts has been derived from the comparison of these BRCA1 mutant breast tumours and matched sporadic controls. Functional analysis of this gene list has identified the key genes and molecular pathways that are deregulated in these tumours. BRCA1 deficiency was associated with deregulation of pathways involved in: (1) immune response, (2) metastasis and invasion, (3) cytoskeletal remodelling, (4) spindle assembly and chromosome separation, (5) apoptosis and survival. Validation of the key genes underlying this BRCA1-deficient breast cancer profile has been performed. Conclusions

This approach has revealed a set of transcripts that could potentially be used to identify both hereditary and sporadic breast cancer patients with BRCA1- deficiency. The ability to perform gene expression profiling from FFPE derived breast tissue could also have significant clinical application.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-04-02.

Abstract B35: High-throughput cell line profiling for identification of anticancer drug sensitivity and resistance biomarkers with OncoPredictor

Tumor derived cell lines have been in use for cancer drug profiling as evidenced by the establishment of NCI-60 panel as a drug discovery tool in early 1990s. In recent years, due to the advancement of targeted therapies in cancer, screening of larger cell panels with greater genetic heterogeneity has become very important not only to measure efficacy of the compounds but also for identifying the biomarkers that are responsible for the efficacy. Here we present data from OncoPredictorSM, a cellular screening and bioinformatics platform able to (1) evaluate multiple types of genomic biomarkers for association with in vitro drug response and (2) analyze identified biomarkers in clinical tumor populations, thereby suggesting potential drug development strategies. The cellular screening component, OncoPanel™, is comprised of a large panel of human tumor-derived cell lines from different origins with broad genetic heterogeneity providing a sensitive method of comparing proliferation or cytotoxicity (resistance or sensitivity) across genotypes. Our cell line panel consists of 240 cell lines that span a wide variety tumor tissue types including lung, breast, stomach, colon, ovary, liver, skin, kidney, bladder, prostate, pancreas, head and neck, brain, hematopoetic, and lymphoid tumors. We have mRNA expression, SNP and mutation data to characterize these cell lines. The media and culture conditions are standardized and optimized so that the genetic heterogeneity of the cell line will be responsible for the phenotypic responses obtained. We generate simultaneous data for each compound at 10 concentrations (in triplicates) resulting in precise IC50/EC50 values for analysis and comparison. Results from a case study will be presented to depict the very robust data quality including the doubling time for the cell lines. Also, sensitive and resistance data with 11 known anticancer agents including inhibitors of mTorr, ABL, MEK, PDGF, VEGF, FLT3, Aurora kinases, HSP90, EGFR, Topo II, and microtubulin disassembly will be presented using the robust high content data from these cell lines. As expected, the most sensitive cell lines against a clinical ABL inhibitor were the CML-derived cell lines. On the other hand, many of the colon, melanoma and pancreatic cell lines were sensitive to MEK inhibitor. Sensitive and resistant cells were further profiled against, mutation, expression, and SNP data to identify genes involved in the sensitive/resistant phenotypes using sophisticated bioinformatic analysis tools to identify genomic biomarker profiles and to estimate their frequency in clinical populations (data presented separately). OncoPredictor is ideally suited for prioritization of the leads, positioning of the leads against cancer types, repositioning of clinical candidates or drugs for supplemental indication, combination therapies, and for biomarker identification and characterization in clinical populations.

Citation Information: Clin Cancer Res 2010;16(14 Suppl):B35.

Emerging technologies for pediatric and adult trauma care

PURPOSE OF REVIEW

Current Emergency Medical Service protocols rely on provider-directed care for evaluation, management and triage of injured patients from the field to a trauma center. New methods to quickly diagnose, support and coordinate the movement of trauma patients from the field to the most appropriate trauma center are in development. These methods will enhance trauma care and promote trauma system development.

RECENT FINDINGS

Recent advances in machine learning, statistical methods, device integration and wireless communication are giving rise to new methods for vital sign data analysis and a new generation of transport monitors. These monitors will collect and synchronize exponentially growing amounts of vital sign data with electronic patient care information. The application of advanced statistical methods to these complex clinical data sets has the potential to reveal many important physiological relationships and treatment effects.

SUMMARY

Several emerging technologies are converging to yield a new generation of smart sensors and tightly integrated transport monitors. These technologies will assist prehospital providers in quickly identifying and triaging the most severely injured children and adults to the most appropriate trauma centers. They will enable the development of real-time clinical support systems of increasing complexity, able to provide timelier, more cost-effective, autonomous care.

First aid provision in nightclubs and other entertainment venues

This article discusses the role and responsibilities of the registered nurse in providing first aid in challenging environments, such as crowded nightclubs. Basic assistance for common emergencies, including substance misuse, wounds, choking and anaphylaxis, are discussed. This article emphasises the importance of risk assessment and reminds readers of the need to maintain personal safety.

Introduction to the nurse's role in providing first aid

This article, the first in an eight-part series, discusses the importance of a considered, responsible approach to first aid. The article describes the challenges of working outside one's clinical environment and describes the legal background to undertaking first aid.

GPs' experiences of primary care mental health research: a qualitative study of the barriers to recruitment

OBJECTIVE

To investigate the perceived barriers among GPs towards introducing participation in randomized controlled trials (RCTs) to patients presenting with depression during consultations.

METHODS

Qualitative study using semi-structured interviews. Interviews were recorded using a digital voice recorder, transcribed verbatim and analysed using the Framework Approach. The participants were 41 GPs from five primary care trusts in the South West who were collaborating with the University of Bristol on an RCT recruiting patients with depression.

RESULTS

Three themes were identified: (i) concern about protecting the vulnerable patient and the impact on the doctor-patient relationship; (ii) the perceived lack of skill and confidence of GPs to introduce a request for research participation within a potentially sensitive consultation; and (iii) the priority given to clinical and administrative issues over research participation. These themes were underpinned by GPs' observations that consultations with people about depression differed in content, style and perceived difficulty compared to other types of consultations.

CONCLUSION

Depressed patients were often viewed as vulnerable and in need of protection and it was seen as difficult and intrusive to introduce research. Patients were not always given the choice to participate in research in the same way that they are encouraged to participate in treatment decision making. A lack of skills in introducing research could be addressed with training through the new Primary Care Research Network. A more radical change in clinician attitudes and policy may be needed in order to give research a higher priority within primary care.

Increasing body weight predicts the earlier onset of insulin-dependant diabetes in childhood: testing the 'accelerator hypothesis' (2)

AIMS AND METHODS

It has recently been hypothesized that weight gain in childhood accelerates the onset of Type 1 diabetes, as well as increasing its risk, and that Type 1 diabetes and Type 2 diabetes may be one and the same disorder of insulin resistance. An explanation is needed for the rising incidence of childhood diabetes and, to test the Accelerator Hypothesis, we examined the anthropometric measurements recorded from birth in 168 young people presenting with Type 1 diabetes between 1980 and 2002. Pre-onset as well as peri- and post-onset measurements of height and weight were available, and waist circumference was recorded at various intervals after onset.

RESULTS

The mean birth weight of the children and their height, weight and body mass index (BMI) at diagnosis lay close to the population mean. However, pre-onset and post-onset BMI were both well above the population mean, were closely correlated with each other (r = 0.79, P < 0.001) and (inversely) with age at onset (r = -0.30, P < 0.001). A significant correlation was also found between BMI standard deviation scores (sds) and year of diagnosis (r = 0.27, P < 0.001) and, importantly, waist circumference sds in the children with Type 1 diabetes was found to be substantially greater than average for the population [boys: +0.96 (sd 1.04), girls: +1.30 (sd 0.89)].

CONCLUSIONS

The data suggest that children with Type 1 diabetes have become progressively heavier at diagnosis over the past 20 years, and that the heavier child develops it earlier. Waist circumference, a proxy for visceral fat mass and insulin resistance, is substantially greater in children with Type 1 diabetes. Weight centile crossing appears to be an important environmental accelerator which may contribute to or account for the striking increase in both Type 1 diabetes and Type 2 diabetes in childhood. A reduction of body weight and improved lifestyle might reverse this trend in both types of diabetes.

Personality functioning: the influence of stature

BACKGROUND

The Wessex Growth Study has monitored the psychological development of a large cohort of short normal and average height control participants since school entry.

AIMS

To examine the effect of stature on their personality functioning now that they are aged 18-20 years.

METHODS

This report contains data from 48 short normal and 66 control participants. Mean height SD score at recruitment was: short normals -2.62 SD, controls -0.22 SD. Final height SD score was: short normals -1.86, controls 0.07. The Adolescent to Adult Personality Functioning Assessment (ADAPFA) measures functioning in six domains: education and employment, love relationships, friendships, coping, social contacts, and negotiations.

RESULTS

No significant effect of recruitment height or final height was found on total ADAPFA score or on any of the domain scores. Socioeconomic status significantly affected total score, employment and education, and coping domain scores. Gender had a significant effect on total score, love relationships, coping, and social contacts domain scores. Salient aspects of daily living for this sample were identified from the interviews (prevalence%): consuming alcohol (94%), further education (63%), love relationships (55%), current drug use (29%), experience of violence (28%), parenthood (11%), and unemployment (9%). Stature was not significantly related to behaviour in any of these areas.

CONCLUSIONS

Despite previously reported links between short stature and poorer psychosocial adaptation, no evidence was found that stature per se significantly affected the functioning of the participants in these areas as young adults.

Hormones and handedness

BACKGROUND

The Wessex Growth Study has monitored the growth and psychological development of short normal (SN) and average height control subjects since they entered school in 1985/1986. During psychometric testing, we found that 25% SN compared to 9% control subjects wrote with their left hand. The short group also attained significantly lower scores on measures of IQ and attainment and displayed less internalisation of control. Laterality, however, is thought to be influenced by the intrauterine environment and has been associated with pubertal delay. At recruitment, short children had a relatively low birth weight, delayed bone age and were more likely than controls to be short for family.

OBJECTIVES

To determine if birth conditions were associated with lateral preference and whether laterality could account for the differences found during the psychometric assessment or predict pubertal timing of SN children.

METHODS

Subjects were classified as right- (RH) or left-handed (LH) according to the writing hand and the data were investigated examining the effect of handedness and stature.

RESULTS

RH and LH SN children were no more likely to suffer birth complications than those of average height. Psychometric testing did not reveal any significant differences between RH and LH SN children and their patterns of growth appeared to be similar. However, both RH and LH SN children scored less well on tests of cognitive ability and analyses of covariance revealed significant gender/handedness effects for both the timing of puberty and final height.

CONCLUSIONS

The increase in left-handedness among SN children did not appear to be related to adverse birth conditions, but it may be that the hormones responsible for growth and development also play some part in brain laterality and cognitive development.

Measuring and improving patients' and families' perceptions of care in a system of pediatric hospitals

BACKGROUND

Shriners Hospitals for Children (SHC) is a network of 22 pediatric specialty hospitals that provide medical care free of charge to children up to 18 years of age and that serve as referral centers for children with complex orthopedic and burn problems. In 1998 the SHC system began using The Picker Institute's Patient and Family Perception of Care inpatient survey throughout its hospitals.

SYSTEMWIDE IMPLEMENTATION

A broad-based implementation plan was developed to promote acceptance of the perception of care topic and provide education on performance improvement. In 1999 a work group was formed to prioritize areas for improvement, survey benchmark hospitals, and identify best practices in benchmark hospitals. This work group first focused on the dimensions of Partnership Between Families and Clinicians and Information and Education to the Child. In May 1999 the work group began the task of identifying best practices in these two priority dimensions from the SHC benchmark hospitals. Surveys were submitted to those hospitals, asking what they perceived as being the reasons they scored well in those areas. The results of these surveys were used to identify key practices in these benchmark hospitals that are of significant importance in patient and family perceptions of quality care.

NEXT STEPS

The challenge is to facilitate cross-facility interactions to understand and adopt best practices. Focus groups will be conducted to further delineate the dimensions with higher problem scores. The SHC system plans to expand the patient surveys to outpatients, to allow for the evaluation of the full complement of hospital patients.

Bone dysplasia sclerosteosis results from loss of the SOST gene product, a novel cystine knot-containing protein

Sclerosteosis is an autosomal recessive sclerosing bone dysplasia characterized by progressive skeletal overgrowth. The majority of affected individuals have been reported in the Afrikaner population of South Africa, where a high incidence of the disorder occurs as a result of a founder effect. Homozygosity mapping in Afrikaner families along with analysis of historical recombinants localized sclerosteosis to an interval of approximately 2 cM between the loci D17S1787 and D17S930 on chromosome 17q12-q21. Here we report two independent mutations in a novel gene, termed "SOST." Affected Afrikaners carry a nonsense mutation near the amino terminus of the encoded protein, whereas an unrelated affected person of Senegalese origin carries a splicing mutation within the single intron of the gene. The SOST gene encodes a protein that shares similarity with a class of cystine knot-containing factors including dan, cerberus, gremlin, prdc, and caronte. The specific and progressive effect on bone formation observed in individuals affected with sclerosteosis, along with the data presented in this study, together suggest that the SOST gene encodes an important new regulator of bone homeostasis.

Pubertal growth of the short normal girl

OBJECTIVES

To determine the timing, magnitude and duration of the pubertal spurt for short normal and average height girls, to compare these with Tanner's standard and to investigate predictors of pubertal growth.

METHODS

The growth of 46 short normal and 55 control girls, identified at school entry, was monitored throughout puberty. Height and weight were measured at 6-month intervals from which body mass index (BMI) was derived. Annual velocities were calculated and used to estimate the age and magnitude of peak height velocity (PHV). Age of menarche was recorded to the nearest month. Parents provided information on the child's medical and social history.

RESULTS

The mean age at PHV, the magnitude of PHV and age at menarche were similar for both groups and close to Tanner's 50th centile values. Pre-pubertal BMI predicted age at menarche for short and control girls, accounting for 17% of the variance. There was a tendency for early maturing girls of average stature to have greater PHV. However, this relationship was not observed in short girls, nor did any other variable, genetic or environmental, predict the timing or magnitude of their pubertal spurt.

CONCLUSIONS

Delayed puberty in short normal girls is unlikely and their growth during puberty is comparable to girls of average height. The pubertal variables measured remain close to Tanner's original standards for both groups, suggesting the lack of a secular trend towards earlier puberty in girls. The onset of menstruation is influenced by pre-pubertal BMI. However, the clinician should be aware that short normal girls have normal pubertal growth and that no genetic or environmental variable can predict the timing or magnitude of their growth spurt.

The medical management of adolescent heroin dependence

The use of heroin by American adolescents is at its highest levels since the heroin epidemic of the 1960s. This clinical perspective reviews medical issues associated with adolescent heroin dependence. Older, as well as potential newer, treatments for adolescent heroin dependence are discussed. Multiple obstacles face a heroin-dependent adolescent who seeks treatment, including a lack of evidenced-based research on pharmacotheraputic agents for this population, strict restrictions on medications with demonstrated efficacy in adults, and a general lack of clinical experience in treating this population.

Congenital radioulnar synostosis in an active duty soldier: case report and literature review

Congenital radioulnar synostosis (CRS) is a developmental deformity that interferes with pronation and supination of the upper extremity. CRS often results in functional, cosmetic, and cultural limitations. The purpose of this paper is to present a patient with CRS who is currently functioning as a generator mechanic in the U.S. Army and to review the literature for current treatment options. We know of no other individual in the U.S. Army who is on active duty status with this deformity.