Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology

OBJECTIVES

The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes.

METHODS

Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology.

RESULTS

The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis.

CONCLUSIONS

Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis.

FUNDING

This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.

The New York State SARS-CoV-2 Testing Consortium: Regional Communication in Response to the COVID-19 Pandemic

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, created an unprecedented need for comprehensive laboratory testing of populations, in order to meet the needs of medical practice and to guide the management and functioning of our society. With the greater New York metropolitan area as an epicenter of this pandemic beginning in March 2020, a consortium of laboratory leaders from the assembled New York academic medical institutions was formed to help identify and solve the challenges of deploying testing. This report brings forward the experience of this consortium, based on the real-world challenges which we encountered in testing patients and in supporting the recovery effort to reestablish the health care workplace. In coordination with the Greater New York Hospital Association and with the public health laboratory of New York State, this consortium communicated with state leadership to help inform public decision-making addressing the crisis. Through the length of the pandemic, the consortium has been a critical mechanism for sharing experience and best practices in dealing with issues including the following: instrument platforms, sample sources, test performance, pre- and post-analytical issues, supply chain, institutional testing capacity, pooled testing, biospecimen science, and research. The consortium also has been a mechanism for staying abreast of state and municipal policies and initiatives, and their impact on institutional and laboratory operations. The experience of this consortium may be of value to current and future laboratory professionals and policy-makers alike, in dealing with major events that impact regional laboratory services.

Adoption of electronic hand hygiene monitoring systems in New York state hospitals and the associated impact on hospital-acquired C. difficile infection rates

BACKGROUND

Approximately 721,800 hospital acquired infections occur annually, generating an estimated $10 billion in provider costs. Proper hand hygiene (HH) prevents hospital acquired infections, yet compliance is low. Electronic hand hygiene monitoring systems (EHHMS) are a potential solution, tracking and signaling HH events.

METHODS

We explored adoption of EHHMS in New York State acute care hospitals through a survey and interviews. Trend analysis was used to evaluate the impact of EHHMS on hospital-acquired Clostridium difficile infection (HA-CDI) rates.

RESULTS

Survey respondents represented approximately 30% (N = 56) of the total population of hospitals (N = 184) and EHHMS adoption was low (N = 2). The primary reason for nonadoption was cost (79.6%). HH compliance increased 20%-30% and HA-CDI decreased 70% for one hospital after an EHHMS, though not sustained; robust HH culture was mentioned as a necessary accompaniment. The trend analysis showed negligible impact on HA-CDI post-EHHMS for the second hospital. A critical access hospital without an EHHMS reported HH compliance of 90% attributed to strong HH culture.

CONCLUSIONS

Proliferation of EHHMS is low in New York State acute care hospitals and its impact on HH compliance and infection rates is questionable. Putting technology aside, strong HH culture seems essential for high compliance.

Regulation of Trophic Factor Expression by Innervating Target Regions in Intraocular Double Transplants

Trophic factors have been found to play a significant role both in long-term survival processes and in more rapid and dynamic processes in the brain and spinal cord. However, little is known regarding the regulation of expression of growth factors, and how these proteins interact on a cell-to-cell basis. We have studied protein levels of one growth factor known to affect the noradrenergic innervation of the hippocampal formation, namely brain-derived neurotrophic factor (BDNF). The purpose of the present study was to determine if appropriate innervation or contact between the LC noradrenergic neurons and their target, the hippocampus, affects expression of this growth factor in either brain region. Fetal brain stem tissue, containing the LC, and hippocampal formation were dissected from embryonic day 17 rat fetuses and transplanted together or alone into the anterior chamber of the eye of adult Fisher 344 rats. The tissue was grown together for 6 weeks, after which the animals were sacrificed and ELISAs for BDNF were undertaken. Transplantation to the anterior chamber of the eye increased the expression of BDNF in the hippocampal but not the brain stem tissue, compared with levels observed in fetal and adult rats in vivo. In addition, double grafting with hippocampal tissue more than tripled BDNF levels in brain stem grafts and doubled BDNF levels in the hippocampal portion of double grafts compared with hippocampal single grafts. Triple grafts containing basal forebrain, hippocampus, and brain stem LC tissue increased brain stem and hippocampal BDNF levels even further. Colchicine treatment of LC-hippocampal double grafts gave rise to a significant decrease in hippocampal BDNF levels to levels seen in single hippocampal grafts, while only a partial reduction of BDNF levels was seen in the brain stem portion of the same double grafts treated with colchicine. The findings suggest that an appropriate hippocampal innervation or contact with its target tissues is essential for regulation of BDNF expression in the brain stem, and that retrograde transport of BDNF can occur between double grafted fetal tissues in oculo.

ImmunoglobuliN in the Treatment of Encephalitis (IgNiTE): protocol for a multicentre randomised controlled trial

INTRODUCTION

Infectious and immune-mediated encephalitides are important but under-recognised causes of morbidity and mortality in childhood, with a 7% death rate and up to 50% morbidity after prolonged follow-up. There is a theoretical basis for ameliorating the immune response with intravenous immunoglobulin (IVIG), which is supported by empirical evidence of a beneficial response following its use in the treatment of viral and autoimmune encephalitis. In immune-mediated encephalitis, IVIG is often used after a delay (by weeks in some cases), while diagnosis is confirmed. Wider use of IVIG in infectious encephalitis and earlier use in immune-mediated encephalitis could improve outcomes for these conditions. We describe the protocol for the first ever randomised control trial of IVIG treatment for children with all-cause encephalitis.

METHODS AND ANALYSIS

308 children (6 months to 16 years) with a diagnosis of acute/subacute encephalitis will be recruited in ∼30 UK hospitals and randomised to receive 2 doses (1 g/kg/dose) of either IVIG or matching placebo, in addition to standard treatment. Recruitment will be over a 42-month period and follow-up of each participant will be for 12 months post randomisation. The primary outcome is 'good recovery' (score of 2 or lower on the Glasgow Outcome Score Extended-paediatric version), at 12 months after randomisation. Additional secondary neurological measures will be collected at 4-6 weeks after discharge from acute care and at 6 and 12 months after randomisation. Safety, radiological, other autoimmune and tertiary outcomes will also be assessed.

ETHICS AND DISSEMINATION

This trial has been approved by the UK National Research Ethics committee (South Central-Oxford A; REC 14/SC/1416). Current protocol: V4.0 (10/03/2016). The findings will be presented at national and international meetings and conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBERS

NCT02308982, EudraCT201400299735 and ISRCTN15791925; Pre-results.

Redesigning care to meet national recommendation of four or more yearly clinic visits in patients with cystic fibrosis

Cystic fibrosis (CF) is a chronic disease requiring patients to have frequent specialty healthcare visits to delay progression of lung disease, prevent and treat failure to thrive and initiate early interventions to prevent acute illness and complications. The CF Foundation recommends that patients have visits with the CF care team at least every 3 months. During participation in the CF Foundation Learning and Leadership Collaborative IV, the CF team at Arkansas Children's Hospital initiated quality improvement work with the aim to increase the percentage of patients attending clinic four or more times a year from 35% in 2004 and 56% in 2005 (CF Foundation Registry data) to 90% or greater. We redesigned our scheduling system, rescheduled missed patient appointments in a timely fashion and created a process to monitor attendance. This quality improvement work led to a sustained increase in the percentage of patients attending clinic visits four or more times a year reaching our goal of 90% in 2012. Improvements were also noted in the number of patients with body mass index/weight-for-length centile of 25 or greater, which could be related to more frequent clinic attendance.

A simple probabilistic model of submicroscopic diatom morphogenesis

Unicellular algae called diatoms morph biomineral compounds into tough exoskeletons via complex intracellular processes about which there is much to be learned. These exoskeletons feature a rich variety of structures from submicroscale to milliscale, many that have not been reproduced in vitro. In order to help understand this complex miniature morphogenesis, here we introduce and analyse a simple model of biomineral kinetics, focusing on the exoskeleton's submicroscopic patterned planar structures called pore occlusions. The model reproduces most features of these pore occlusions by retuning just one parameter, thereby indicating what physio-biochemical mechanisms could sufficiently explain morphogenesis at the submicroscopic scale: it is sufficient to identify a mechanism of lateral negative feedback on the biomineral reaction kinetics. The model is nonlinear and stochastic; it is an extended version of the threshold voter model. Its mean-field equation provides a simple and, as far as the authors are aware, new way of mapping out the spatial patterns produced by lateral inhibition and variants thereof.

Voxel-wise magnetization transfer imaging study of effects of natalizumab and IFNβ-1a in multiple sclerosis

Objective:

To determine the effects of intravenous natalizumab and intramuscular interferon beta-1a (IFNβ-1a) on the volume of white-matter (WM) lesions and normal appearing brain tissue (NABT) undergoing voxel-wise (VW) increases in magnetization transfer ratio (MTR) suggestive of remyelination in patients with relapsing multiple sclerosis.

Methods:

This prospective, open-label, single-blinded study enrolled patients with relapsing–remitting multiple sclerosis (RRMS) and relapsing secondary progressive multiple sclerosis (RSPMS) as well as a group of age/sex-matched healthy controls ( n=22). Patients with multiple sclerosis were assigned to receive natalizumab monotherapy ( n=77; RRMS/RSPMS) or intramuscular IFNβ-1a ( n=26) as either monotherapy (RRMS) or combined with pulsed i.v. methylprednisolone, as needed (RSPMS). The primary endpoint was the two-year change in volume of NABT VWMTR, by quantifying the number of voxels that increased (suggesting remyelination) or decreased (suggesting demyelination) in their MTR value.

Results:

The volume of tissue undergoing increases in VWMTR was significantly larger in natalizumab compared with IFNβ-1a-treated patients (year 1: p=0.001 in NABT and p<0.006 in WM lesions; year 2: p=0.008 in NABT) and compared with healthy control subjects (year 1: p=0.05 and year 2: p=0.007 in NABT). The larger volume within NABT undergoing decreases in VWMTR was detected in multiple sclerosis patients compared with healthy controls ( p<0.001), and in the IFNβ-1a group compared with the natalizumab group (year 1: p=0.05; year 2: p=0.002). One patient on natalizumab died from progressive multifocal leukoencephalopathy eight months after completing the study.

Conclusion:

Natalizumab may promote remyelination and stabilize demyelination in lesions and NABT in relapsing multiple sclerosis, compared with intramuscular IFNβ-1a.

No association between conventional brain MR imaging and chronic cerebrospinal venous insufficiency in multiple sclerosis

BACKGROUND AND PURPOSE

CCSVI has been reported to occur at high frequency in MS. Its significance in relation to MR imaging parameters also needs to be determined, both in patients with MS and HCs. Therefore, this study determined the associations of CCSVI and conventional MR imaging outcomes in patients with MS and in HCs.

MATERIALS AND METHODS

T2, T1, and gadolinium lesion number, LV, and brain atrophy were assessed on 3T MR imaging in 301 subjects, of whom 162 had RRMS, 66 had secondary-progressive MS subtype, and 73 were HCs. CCSVI was assessed using extracranial and transcranial Doppler evaluation. The MR imaging measure differences were explored with 27 borderline cases for CCSVI, added to both the negative and positive CCSVI groups to assess sensitivity of the results of these cases.

RESULTS

No significant differences between subjects with and without CCSVI were found in any of the individual diagnostic subgroups or MS disease subtypes for lesion burden and atrophy measures, independently of the CCSVI classification criteria used, except for a trend for higher T2 lesion number (irrespective of how borderline cases were classified) and lower brain volume (when borderline cases were included in the positive group) in patients with RRMS with CCSVI. No CCSVI or MR imaging differences were found between 26 HCs with, or 47 without, a familial relationship.

CONCLUSIONS

CCSVI is not associated with more severe lesion burden or brain atrophy in patients with MS or in HCs.

Demonstration of ignition radiation temperatures in indirect-drive inertial confinement fusion hohlraums

We demonstrate the hohlraum radiation temperature and symmetry required for ignition-scale inertial confinement fusion capsule implosions. Cryogenic gas-filled hohlraums with 2.2 mm-diameter capsules are heated with unprecedented laser energies of 1.2 MJ delivered by 192 ultraviolet laser beams on the National Ignition Facility. Laser backscatter measurements show that these hohlraums absorb 87% to 91% of the incident laser power resulting in peak radiation temperatures of T(RAD)=300 eV and a symmetric implosion to a 100 μm diameter hot core.

Magnetic resonance imaging characteristics of children and adults with paediatric-onset multiple sclerosis

The purpose of this study was to compare the clinical and quantitative magnetic resonance imaging metrics of paediatric-onset multiple sclerosis to adult-onset multiple sclerosis. It was a prospective comparison of clinical and magnetic resonance imaging characteristics of two paediatric onset multiple sclerosis and two adult onset multiple sclerosis groups that were matched for disease duration. The paediatric-onset-C group consisted of children with paediatric-onset multiple sclerosis with mean disease duration of 2.7 years, whereas the paediatric onset-A group consisted of adults with mean disease duration of 20 years. The adult onset multiple sclerosis-1 and adult onset multiple sclerosis-2 groups were matched to the paediatric onset-C and paediatric onset-A groups. The brain magnetic resonance imaging measures included: T(1)-, T(2)- and gadolinium contrast-enhancing volumes and the T(2)-lesion volume relative magnetization transfer ratio, global and tissue specific white and grey matter brain atrophy and normal appearing grey and white matter magnetization transfer ratio. Regression analyses were employed for magnetic resonance imaging measures. The paediatric onset multiple sclerosis-C (n = 17) and adult onset multiple sclerosis-1 (n = 81) groups had mean disease duration values of 2.7 +/- standard deviation 2.0 and 2.6 +/- 1.1 years, respectively. The paediatric onset multiple sclerosis-A group (n = 33) and adult onset multiple sclerosis-2 group (n = 300) had mean disease durations of 20 +/- standard deviation 10.9 and 20 +/- 9.3 years, respectively. In regression analysis, the T(2)- lesion volume of the paediatric onset multiple sclerosis-C and adult onset multiple sclerosis-1 groups were similar but there was a trend toward higher T(1)- lesion volume (P = 0.028) in the paediatric onset group. The brain parenchymal fraction and grey matter fraction in the paediatric-onset multiple sclerosis-C group were higher than those for the adult onset multiple sclerosis-1 group (both P < 0.001). The frequency of progressive multiple sclerosis in the paediatric onset multiple sclerosis-A group (27.3%) trended lower (odds ratio = 0.43, P = 0.042) than that in the adult onset multiple sclerosis-2 group (46.3%). The Expanded Disability Status Scale (median; inter-quartile range) in the paediatric onset multiple sclerosis-A group (2.25; 2.5) trended lower (P = 0.058) compared with the adult onset multiple sclerosis-2 group (3.5; 4.0). There was a trend toward lower magnetization transfer ratio values in T(2)-lesions, normal appearing grey matter and normal appearing white matter and higher grey matter fraction in the paediatric onset multiple sclerosis-A group compared with the adult onset multiple sclerosis-2 group. There was no evidence for differences on T(2)-lesion volume, T(1)-lesion volume, brain parenchymal fraction or white matter fraction. Paediatric-onset multiple sclerosis is characterized by a significant disease burden both early and later in the disease course. Despite this, disability is slower to accrue in paediatric onset multiple sclerosis than adult onset multiple sclerosis.

Multiplex serum cytokine monitoring as a prognostic tool in rheumatoid arthritis

OBJECTIVE

Early optimized therapy of rheumatoid arthritis (RA) results in improved outcomes. The initiation of optimized therapy is hindered by the difficulty of early diagnosis and the limitations of current disease activity and therapeutic response assessment tools. Identifying patients requiring early combination DMARD/biologic therapy is currently a significant clinical challenge given the lack of definitive prognostic criteria. Since cytokines are soluble intracellular signaling molecules that modulate disease pathology in RA, we tested the recent conjecture that en mass serum cyto-kine measurement and monitoring will provide a useful tool for effective therapeutic management in RA.

METHODS

We assayed the levels of 16 serum cytokines in 18 RA patients treated prospectively with methotrexate and from 18 unaffected controls. Specific mechanistic aspects of inflammatory pathology in the periphery could be discerned on a patient-specific basis from patients' serum cytokine profiles, information that may aid in the design of anti-cytokine biologic therapy. A serum Cytokine Activity Index (CAI) was also created using multi-variant analysis methods.

RESULTS

Distinct cytokines were significantly elevated in RA patients relative to controls, and three distinct clusters with correlations to disease activity were identified. The Cytokine Activity Index correlated well with the therapeutic res-ponse; responders and non-responders in this cohort were distinguishable as early as one month post initiation of methotrexate therapy, well before clinical assessments of response are commonly completed.

CONCLUSION

Clinical assessment tools could be derived from this approach that may provide a means to continually track patients, allowing intervention strategies to be better evaluated on a patient-specific basis and to identify residual cytokine activity that could be used to guide combination therapy.

Histopathologic indicators of breast cancer biology: insights from population mammographic screening

Histopathologic features of breast cancer such as tumour size, grade and axillary lymph node (LN) status variably reflect tumour biology and time. Recent evidence suggests that the biological character of breast cancer is established at an early stage and has a major impact on clinical course. The aim of this study was to distinguish the impact of biology on breast cancer histopathology by comparing features of breast cancers diagnosed following population mammographic screening with prevalent vs incident detection and screening interval. Central histopathology review data from 1147 cases of ductal in situ and/or invasive breast cancer were examined. Size, grade and LN status of invasive cancers were positively correlated (P<0.001). Prevalent invasive cancers were larger (P<0.001) and more likely to be LN positive (P=0.02) than incident cases, but grade was not associated with screening episode (P=0.7). Screening interval for incident cancers was positively associated with invasive cancer size (P=0.05) and LN status (P=0.002) but not grade (P=0.1). Together, these data indicate that biology and time both impact on size and LN status of invasive breast cancer, but grade reflects biology alone. In view of the clinical importance of breast cancer biology, grade as its most direct indicator assumes particular significance.

Regulation of trophic factor expression by innervating target regions in intraocular double transplants

Trophic factors have been found to play a significant role both in long-term survival processes and in more rapid and dynamic processes in the brain and spinal cord. However, little is known regarding the regulation of expression of growth factors, and how these proteins interact on a cell-to-cell basis. We have studied protein levels of one growth factor known to affect the noradrenergic innervation of the hippocampal formation, namely brain-derived neurotrophic factor (BDNF). The purpose of the present study was to determine if appropriate innervation or contact between the LC noradrenergic neurons and their target, the hippocampus, affects expression of this growth factor in either brain region. Fetal brain stem tissue, containing the LC, and hippocampal formation were dissected from embryonic day 17 rat fetuses and transplanted together or alone into the anterior chamber of the eye of adult Fisher 344 rats. The tissue was grown together for 6 weeks, after which the animals were sacrificed and ELISAs for BDNF were undertaken. Transplantation to the anterior chamber of the eye increased the expression of BDNF in the hippocampal but not the brain stem tissue, compared with levels observed in fetal and adult rats in vivo. In addition, double grafting with hippocampal tissue more than tripled BDNF levels in brain stem grafts and doubled BDNF levels in the hippocampal portion of double grafts compared with hippocampal single grafts. Triple grafts containing basal forebrain, hippocampus, and brain stem LC tissue increased brain stem and hippocampal BDNF levels even further. Colchicine treatment of LC-hippocampal double grafts gave rise to a significant decrease in hippocampal BDNF levels to levels seen in single hippocampal grafts, while only a partial reduction of BDNF levels was seen in the brain stem portion of the same double grafts treated with colchicine. The findings suggest that an appropriate hippocampal innervation or contact with its target tissues is essential for regulation of BDNF expression in the brain stem, and that retrograde transport of BDNF can occur between double grafted fetal tissues in oculo.

MRI predictors of cognition in subcortical ischemic vascular disease and Alzheimer's disease

BACKGROUND

Causes of cognitive impairment in subcortical ischemic vascular disease (SIVD) are less well understood than in AD, but have been thought to result from direct effects of subcortical lacunes and white matter lesions, perhaps related to disruption of important cortical-subcortical pathways.

OBJECTIVE

To examine the relation between cognitive abilities and quantitative MRI measures of subcortical cerebrovascular disease and cortical and hippocampal atrophy.

METHODS

Subjects were 157 participants in a multicenter study of SIVD and AD who included cognitively normal, cognitively impaired, and demented individuals with and without subcortical lacunar infarcts. Dependent variables were neuropsychological tests of global cognitive function, memory, language, and executive function. Independent variables were quantitative MRI measures of volume of lacunar infarcts in specific subcortical structures, volume of white matter lesion (WML), volume of cortical gray matter (cGM), and total hippocampal volume (HV). Multiple regression analyses were used to identify MRI predictors of cognition.

RESULTS

Subcortical lacunes were not related to cognitive measures independent of effects of other MRI variables. WML was independently related to selected, timed measures. HV and cGM were strong and independent predictors of cognitive variables, with effects that did not differ in subjects with and without subcortical lacunes.

CONCLUSIONS

Results suggest that cognitive impairment associated with subcortical ischemic vascular disease is primarily a result of associated hippocampal and cortical changes.

Custody planning. a retrospective review of oncology patients who were single parents

With rising numbers of single-parent families, a phenomenon becoming increasingly prevalent is the child orphaned by cancer. We sought to examine issues related to custody planning addressed prior to the patient's death. Ten deceased patients with minor children were identified. The contact person was administered a brief questionnaire regarding the minor children and custody issues. The study involved twenty children, ages ranging from 3-20, mean age 9.8. Only five of the ten families developed custody plans that were ultimately successful. One-half of the families reported the patient had suffered with this issue and almost one-half of the children were not aware of the custody plans that had been arranged for them. In 40% of the cases, the children ultimately went to people to whom the deceased parents were opposed. It is our belief that if we can improve these statistics, we might improve the quality of life of these families.

Home phototherapy for neonatal jaundice--technology and teamwork meeting consumer and service need

32 babies with uncomplicated physiological jaundice received home phototherapy from a hospital/community team in southern Brisbane. All babies showed acceptable reductions in their serum bilirubin on home therapy, and none required hospital re-admission for phototherapy. Their families were highly satisfied with the home program, and recorded high levels of confidence in their therapeutic responsibilities. Community providers were able to deliver a high quality 24-hour service, integrated with appropriate neonatology support. The cost of delivering the home program was significantly less than a comparable hospital stay.

Ideomotor apraxia in early Alzheimer's disease: time and accuracy measures

Twenty-six Alzheimer's disease (AD) and 42 healthy control (NC) subjects were evaluated with neuropsychological and apraxia batteries. ADs produced a greater range of error types, but did not differ from NCs in their most frequent error types. Hand sequencing ability contributed significantly to AD praxis with no predictors for NCs. Although groups did not differ in gesture time, the AD group had significantly longer response latencies for periods prior to gesture execution and the effect was prominent for transitive tasks and nondominant hand use. Results illustrate the sensitivity of timing measures in identifying abnormal praxis in early stages of AD.

Impact of psychosocial factors on health outcomes in the elderly. A prospective study

One hundred and thirty-five initially healthy men and women older than 65 years of age were studied prospectively to identify factors associated with health outcomes. At study onset, measures of personality, social interaction, and health locus of control were obtained while participants were still healthy. A reliable health outcome measure was developed, based on the annual objective coding of morbidity. Correlations between variables showed significant associations between age, a less independent personality trait, and poor health outcomes. Anxiety and low levels of social interaction were associated with poor health after 8 years. Gender and health locus of control were not significantly related to health outcomes. A path analysis showed significant direct paths between age and trait anxiety and 8-year health outcomes, and indirect paths between anxiety and extroversion and 8-year health, by way of social interaction. There was no evidence that social interaction mediated the effects of either anxiety or extroversion on health. The structure of psychosocial characteristics of the healthy elderly sample was revealed in the pattern of correlations between personality, social interaction, and locus of control.

Practical classification of chin deformities

A visually pleasing chin is an important component of facial harmony. This study was undertaken to introduce a practical classification of chin dysmorphology, which can be used to guide the surgeon toward the appropriate surgical approach to chin repair. Analysis of life-size photography, based on standard anthropometric measurements, was completed on 2,879 patients from 1981 to 1991. Six hundred eighty-four patients were noted to have normal occlusion with some form of chin deformity. Analysis of this group of patients identified seven categories of chin dysmorphism: Class I, macrogenia (n = 170, 24.9%); Class II, microgenia (n = 435, 63.6%); Class III, combination of macrogenia in one direction and microgenia in the other direction (n = 54, 7.9%); Class IV, asymmetry (n = 4, 0.6%); Class V, soft tissue ptosis ("witch's chin") (n = 13, 1.9%); Class VI, pseudomacrogenia (normal skeletal symphysis menti with excess soft tissue covering) (n = 5, 0.73%); and Class VII, pseudomicrogenia (long-face deformity producing clockwise rotation of the normal mandible) (n = 3, 0.4%). Having diagnosed the dysmorphism, logical surgical recommendations for lower face improvement were postulated. Only patients with Class II chin deformity can be corrected with augmentation. Classes I, III, and IV require an osteotomy of the chin. Classes V and VI benefit from soft tissue correction. Class VII deformity can be corrected with a maxillary osteotomy.

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.

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.

Leadership development for medical students--beyond the prescription pad

BACKGROUND

Physicians are often perceived as leaders in their communities and are expected to participate in politics, business, and volunteer activities. Medical students receive little guidance about becoming effective community leaders.

PROGRAM DESCRIPTION

We developed a leadership training program for medical students. Participation in the program was voluntary. The principal forum for this program was a dinner seminar series, which emphasized presentations by current community leaders and identification of leadership opportunities in which medical students could participate.

PROGRAM EVALUATION

Information collected at the onset of the program identified the students' concern and priorities regarding leadership activities. Seventy-seven percent of participating students identified good communication skills as the most important quality of a leader. In identifying an issue in which physicians might become involved, students noted only medically related issues, such as access to health care. No long term evaluation data are available to assess the effect of this program.

CONCLUSION

Medical school curricula should teach students the leadership skills they will need to participate in community activities.

Acute myeloid leukemia in elderly adults

One hundred and fifteen previously untreated adults aged over 60 years were referred to St Bartholomew's Hospital between 1978 and 1986 for management of acute myeloid leukemia (AML). Twenty-seven patients received symptomatic or palliative treatment only because combination chemotherapy was considered inappropriate. Eighty-eight patients received intensive chemotherapy with curative intent. There was a 48 per cent 'early death' rate and a 24 per cent incidence of resistant disease; complete remission (CR) was achieved in 25/88 patients (28 per cent). By multivariate analysis, a blast count less than 50 x 10(9)/l at presentation was the only factor predictive for achievement of CR whilst the latter and a presentation blast count less than 50 x 10(9)/l predicted for superior survival. Treatment was often curtailed on account of unacceptable toxicity; only 2/88 patients received the planned six cycles of treatment. Two patients died in CR. Four patients are alive in first CR at 3-9 years from treatment; one is alive in second CR following meningeal relapse. Overall survival was significantly worse than that of a contemporaneous group of adults aged 15-59 years treated at this hospital, but duration of CR was comparable. There are great difficulties involved in the intensive treatment of AML in elderly adults, but the major survival benefit gained by achieving CR should stimulate the search for better tolerated but still curative regimens.

A prospective study of response to stressful life events in initially healthy elders

Behavioral and physiological reactions to the stress of a major life crisis were studied prospectively in a group of healthy elderly individuals. Significant decreases in caloric intake, body weight, and lymphocyte count were found following the stressful event with a return toward baseline levels after a recovery period. Significant increases were found for psychological distress and serum cortisol. The results support the thesis that behavioral and physiological changes occur during an event perceived by an elderly person to be stressful and that such changes can have adverse effects on health.