Child and caregiver voices about inpatient care: What do they report as positive and as needing improvement?

PURPOSE

In pediatric healthcare, patient satisfaction queries exclude children and solicit quantitative ratings from caregivers. We sought satisfaction perspectives from hospitalized children 7 to 17 years and their caregivers by qualitatively analyzing interview responses.

DESIGN AND METHODS

English and Spanish-speaking children and their parents on five inpatient units completed two open-ended questions about their satisfaction at hospital discharge (T1, face to face) and 7 to 10 days later (T2, telephone). The questions asked about what was good and what could be better at the hospital. Responses were analyzed using descriptive semantic content analysis and consensus coding methods.

RESULTS

Patients' mean age was 11.9 years (SD = 3.17); 51% were male. At T1, 362 patients offered 833 responses; 600 parents offered 1496 responses. At T2, 252 patients offered 552 responses; 488 parents offered 1290 responses. At T1 and T2, the most frequent patient response to what was good was 'Staff took good care of me' and for caregivers was 'Staff behaving professionally'. At T1, the most frequent patient response about what could be better was 'more activities for kids', and at T2, 'Nothing' and 'More food options and better food quality'; for caregivers at T1, 'Nothing' and 'Not liking the physical space', and at T2, 'Nothing', and 'More communication and professionalism from hospital staff'.

CONCLUSIONS

Pediatric patients and their caregivers are willing and able to offer perspectives about satisfaction with care, and suggestions for improvement before discharge.

PRACTICE IMPLICATIONS

Pediatric patients and their caregivers' perspectives about care yield actionable recommendations for hospital systems.

Establishing weight-based diagnostic reference levels for neonatal chest X-rays

INTRODUCTION

As weights among neonates can vary from <900 g to >2.5 kg, weight-based Diagnostic Reference Levels (DRLs) specific to the neonatal intensive care unit (NICU) are essential. Repeated radiation exposure to this sensitive patient group raises concerns regarding high cumulative radiation doses and the potential for long-term health detriment. This study aimed to establish weight-based DRLs for neonates undergoing mobile chest radiography (CXR) in the NICU.

METHODS

Neonates were classified into three discrete groups; <1000, 1000-2500 and >2500 g. Data were collected prospectively over three months; 95 DAP values were collected, and five were excluded due to poor technique, leaving 90 patients that met the inclusion criteria for mobile CXR in the NICU. Dose-area-product (DAP) in mGycm², the peak kilovoltage (kVp) and the product of tube current and exposure time (mAs) were retrieved from the Picture Archiving and Communication System (PACS). Images and radiological reports were also analysed to confirm diagnostic image quality (IQ). Local DRLs (LDRLs) were derived using the median DAP, and national DRLs were suggested using the 3rd quartile value.

RESULTS

The proposed LDRLs for neonates weighing <1000 g was 2.7 mGycm², for neonates weighing between 1000 g and 2500 g, it was 3.7 mGycm², and for neonates weighing >2500 g it was 6.6 mGycm². The radiation dose received by the 90 (100%) neonates included in the study fell below 11.4 mGycm²; of these, 82% of the DAP values fell below the study institution's existing LDRL of 7.25 mGycm².

CONCLUSION

Weight-based DRLs provide crucial information on doses to this specific radiation-sensitive group. This work recommends using weight-based categories for DRLs and serves as a benchmark for neonatal CXR standardisation and optimisation.

IMPLICATIONS FOR PRACTICE

The proposed weight-based DRLs can be adopted for neonates' locally, nationally and internationally.

Recommended scoring approach for the pediatric patient-reported outcomes version of the Common Terminology Criteria for Adverse Events

BACKGROUND

Collecting symptom, function, and adverse event (AE) data directly from children and adolescents undergoing cancer care is more comprehensive and accurate than relying solely on their caregivers or clinicians for their interpretations. We developed the pediatric patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (Ped-PRO-CTCAE) measurement system with input from children, parents, and clinicians. Here, we report how we determined the recommended Ped-PRO-CTCAE item scoring approach.

METHODS

Data from 271 patients were analyzed using three scoring approaches: (a) at the AE attribute (frequency, severity, interference) using ordinal and dichotomous measures; (b) a weighted composite AE item score by AE attribute (0.5 - frequency; 1.0 - severity; 1.5 - interference); and (c) overall number of AEs endorsed. Associations of each AE attribute, AE item score, and overall AE score with the Patient-Reported Outcome Measurement Information System (PROMIS) Pediatric measures were examined. The ability of the overall Ped-PRO-CTCAE AE score to identify patients with PROMIS symptom T-scores worse than reference population scores was assessed. Clinician preference for score information display was elicited through interviews with five pediatric oncology clinical trialists.

RESULTS

The diverse scoring approaches yielded similar outcomes, including positive correlations of the Ped-PRO-CTCAE attributes, AE item score, and the overall AEs score with the PROMIS Pediatric measures. Clinicians preferred the most granular display of scoring information (actual score reported by the child and corresponding descriptive term).

CONCLUSIONS

Although three scoring approaches yielded similar results, we recommend the AE attribute level of one score per Ped-PRO-CTCAE AE attribute for its simplicity of use in care and research.

Robotic Uses in Pediatric Care: A Comprehensive Review

PROBLEM

Advances in technology have made robotics acceptable in healthcare and medical environments. The aim of this literature review was to examine how the pediatric population can benefit from robotic therapy and assistance that are currently available or being developed in diverse settings.

ELIGIBILITY CRITERIA

English language full-text publications focusing on pediatric robotic therapy studies for infants and children under the age of 17 indexed in PubMed and CINAHL and published from 2008 to 2018.

SAMPLE

A total of 272 articles were identified, 69 full-text articles were retrieved and assessed for eligibility, and 21 studies were finally used in the literature review.

RESULTS

From 21 studies, all studies reviewed showed that children benefited from robotic therapies were 1) responsive to the therapies and 2) favored robot's presence since the robotic systems increased their attention and ability to participate in tasks. Due to small sample size, results were statistically inconclusive.

CONCLUSIONS

We identified positive findings, where utilizing pediatric robots played vital roles in assisting and enhancing current pediatric and NICU treatments. Overall, our findings suggested that more clinical trials would be essential, but the uses of robots may contribute to the future advancement in pediatric and neonatal healthcare.

IMPLICATIONS

These review and analysis can be used to inform healthcare environments where there is a room for applying robotic assistance, although most studies required further testing with larger sample size to validate their results. This suggests the need for further research for robotics in pediatric and neonatal healthcare.

Concurrent adaptations in maximal aerobic capacity, heat tolerance, microvascular blood flow and oxygen extraction following heat acclimation and ischemic preconditioning

We investigated the effects of: 1) Ischemic pre-conditioning (IPC) plus a concurrent five-day heat acclimation + IPC (IPC + HA), 2) five-day HA with sham IPC (HA), or 3) control (CON) on thermoneutral measurements of endurance performance, resting measures of skeletal muscle oxygenation and blood flow. Twenty-nine participants were randomly allocated to three groups, which included: 1) five-days of repeated leg occlusion (4 x 5-min) IPC at limb occlusive pressure, plus fixed-intensity (55% V˙ O_2max) cycling HA at ~36 °C/40% humidity; 2) HA plus sham IPC (20 mmHg) or 3) or CON (thermoneutral 55% V˙ O_2max plus sham IPC). In IPC + HA and HA, there were increases in maximal oxygen consumption (O_2max) (7.8% and 5.4%, respectively; P < 0.05), ventilatory threshold (V_T) (5.6% and 2.4%, respectively, P < 0.05), delta efficiency (DE) (2.0% and 1.4%, respectively; P < 0.05) and maximum oxygen pulse (O₂pulse-Max) (7.0% and 6.9%, respectively; P < 0.05) during an exhaustive incremental test. There were no changes for CON (P > 0.05). Changes (P < 0.05) in resting core temperature (T_C), muscle oxygen consumption (m V˙ O₂), and limb blood flow (LBF) were also found pre-to-post intervention among the HA and IPC + HA groups, but not in CON (P > 0.05). Five-days of either HA or IPC + HA can enhance markers of endurance performance in cooler environments, alongside improved muscle oxygen extraction, blood flow, exercising muscle efficiency and O₂ pulse at higher intensities, thus suggesting the occurrence of peripheral adaptation. Both HA and IPC + HA enhance the adaptation of endurance capacity, which might partly relate to peripheral changes.

Menthol as an Ergogenic Aid for the Tokyo 2021 Olympic Games: An Expert-Led Consensus Statement Using the Modified Delphi Method

INTRODUCTION

Menthol topical application and mouth rinsing are ergogenic in hot environments, improving performance and perception, with differing effects on body temperature regulation. Consequently, athletes and federations are beginning to explore the possible benefits to elite sport performance for the Tokyo 2021 Olympics, which will take place in hot (~ 31 °C), humid (70% RH) conditions. There is no clear consensus on safe and effective menthol use for athletes, practitioners, or researchers. The present study addressed this shortfall by producing expert-led consensus recommendations.

METHOD

Fourteen contributors were recruited following ethical approval. A three-step modified Delphi method was used for voting on 96 statements generated following literature consultation; 192 statements total (96/96 topical application/mouth rinsing). Round 1 contributors voted to "agree" or "disagree" with statements; 80% agreement was required to accept statements. In round 2, contributors voted to "support" or "change" their round 1 unaccepted statements, with knowledge of the extant voting from round 1. Round 3 contributors met to discuss voting against key remaining statements.

RESULTS

Forty-seven statements reached consensus in round 1 (30/17 topical application/rinsing); 14 proved redundant. Six statements reached consensus in round 2 (2/4 topical application/rinsing); 116 statements proved redundant. Nine further statements were agreed in round 3 (6/3 topical application/rinsing) with caveats.

DISCUSSION

Consensus was reached on 62 statements in total (38/24 topical application/rinsing), enabling the development of guidance on safe menthol administration, with a view to enhancing performance and perception in the heat without impairing body temperature regulation.

The Child's Voice in Satisfaction with Hospital Care

PURPOSE

Patient satisfaction is a quality improvement indicator used to evaluate care. Ratings of patient satisfaction in pediatrics exclude the child voice. We tested the feasibility and acceptability of a new model that included both child and parent satisfaction ratings.

DESIGN AND METHODS

We executed a randomized, two-arm, unblinded cohort study comparing child (aged 7-17 years) and parent reports (Arm 1) to parent report only (Arm 2) among a convenience sample of inpatients at a single urban pediatric medical center. The primary (feasibility and acceptability) and secondary outcomes were assessed at the time of discharge (T1) and approximately 10 days following discharge (T2) (standard timing).

RESULTS

Of 672 screened families, 89.3% (n = 600) enrolled in the study; 362 children and parents were randomized to Arm 1 and 238 parents to Arm 2. Patients (98.6%) and parents (99.8%) indicated preference for providing satisfaction ratings at the time of discharge. Seventy-five percent of families (n = 488) completed T1 and T2; neither child nor parent ratings differed significantly between T1 and T2 nor did parent ratings differ between the two study arms. Nurse friendliness, courtesy, and feeling well cared for were among the highest rated items at T1 and T2 by both children and parents.

CONCLUSIONS

Children 7 to 17 years of age and their parents are willing and like to provide satisfaction with care ratings prior to hospital discharge.

PRACTICE IMPLICATIONS

This measurement model could yield valid findings representative of hospitalized children and their parents, and could become the basis for a new and needed measurement approach for pediatric satisfaction with hospital care.

PROMIS pediatric measures validated in a longitudinal study design in pediatric oncology

PURPOSE

This study assessed the responsiveness to change over time and theorized associations of Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric measures in children and adolescents in treatment for cancer to determine measure readiness for use in cancer clinical trials.

METHODS

We administered eight PROMIS (three symptom, two psychological, and three performance) pediatric short-form measures and the Symptom Distress Scale (SDS) to 96 pediatric oncology patients at three time points during a course of chemotherapy. We assessed responsiveness using paired t tests and generalized estimating equation (GEE) models, calculated standardized response mean (SRM) values for PROMIS measures, and examined scores over three data points (T1-T3). Guided by the theory of unpleasant symptoms (TOUS), we examined associations among the PROMIS measures, the SDS, and other variables using GEE.

RESULTS

The paired t tests showed statistically significant changes in two psychological measures and one performance measure from T1 to T2; three symptom, two psychological and two performance measures from T2 to T3; and three symptom and two psychological measures from T1 to T3. Findings from GEE models indicate PROMIS pediatric measures had statistically significant short-term and long-term changes, controlling for demographic and clinical variables. One performance measure did not achieve significant change at any time point. We found positive support for theorized relationships in the TOUS.

CONCLUSIONS

Most of the PROMIS pediatric measures demonstrated changes over time and had significant relationships as theorized, thus supporting concurrent and construct validity of these measures when administered to pediatric oncology patients during a course of chemotherapy. This evidence supports the measures' readiness for use in clinical trials.

Oral L-menthol reduces thermal sensation, increases work-rate and extends time to exhaustion, in the heat at a fixed rating of perceived exertion

PURPOSE

The study investigated the effect of a non-thermal cooling agent, L-menthol, on exercise at a fixed subjective rating of perceived exertion (RPE) in a hot environment.

METHOD

Eight male participants completed two trials at an exercise intensity between 'hard' and 'very hard', equating to 16 on the RPE scale at ~35 °C. Participants were instructed to continually adjust their power output to maintain an RPE of 16 throughout the exercise trial, stopping once power output had fallen by 30%. In a randomized crossover design, either L-menthol or placebo mouthwash was administered prior to exercise and at 10 min intervals. Power output, [Formula: see text]O₂, heart rate, core and skin temperature was monitored, alongside thermal sensation and thermal comfort. Isokinetic peak power sprints were conducted prior to and immediately after the fixed RPE trial.

RESULTS

Exercise time was greater (23:23 ± 3:36 vs. 21:44 ± 2:32 min; P = 0.049) and average power output increased (173 ± 24 vs. 167 ± 24 W; P = 0.044) in the L-menthol condition. Peak isokinetic sprint power declined from pre-post trial in the L-menthol l (9.0%; P = 0.015) but not in the placebo condition (3.4%; P = 0.275). Thermal sensation was lower in the L-menthol condition (P = 0.036), despite no changes in skin or core temperature (P > 0.05).

CONCLUSION

These results indicate that a non-thermal cooling mouth rinse lowered thermal sensation, resulting in an elevated work rate, which extended exercise time in the heat at a fixed RPE.

Common genetic and environmental contributions to post-traumatic stress disorder and alcohol dependence in young women

BACKGROUND

The few genetically informative studies to examine post-traumatic stress disorder (PTSD) and alcohol dependence (AD), all of which are based on a male veteran sample, suggest that the co-morbidity between PTSD and AD may be attributable in part to overlapping genetic influences, but this issue has yet to be addressed in females.MethodData were derived from an all-female twin sample (n=3768) ranging in age from 18 to 29 years. A trivariate genetic model that included trauma exposure as a separate phenotype was fitted to estimate genetic and environmental contributions to PTSD and the degree to which they overlap with those that contribute to AD, after accounting for potential confounding effects of heritable influences on trauma exposure.

RESULTS

Additive genetic influences (A) accounted for 72% of the variance in PTSD; individual-specific environmental (E) factors accounted for the remainder. An AE model also provided the best fit for AD, for which heritability was estimated to be 71%. The genetic correlation between PTSD and AD was 0.54.

CONCLUSIONS

The heritability estimate for PTSD in our sample is higher than estimates reported in earlier studies based almost exclusively on an all-male sample in which combat exposure was the precipitating traumatic event. However, our findings are consistent with the absence of evidence for shared environmental influences on PTSD and, most importantly, the substantial overlap in genetic influences on PTSD and AD reported in these investigations. Additional research addressing potential distinctions by gender in the relative contributions of genetic and environmental influences on PTSD is merited.

A consultant paediatrician led and public health nurse (PHN) provided Community Enuresis Clinic as a model of care

A dedicated Community Enuresis Clinic was established in 2004 in Cavan and Monaghan. The service was audited using ERIC (Education and Resources for Improving Childhood Continence) guidelines. There were 106 males and 47 females, giving an M: F ratio of 2.3:1. Monosymptomatic Nocturnal Enuresis (MNE) accounted for 127 (83%). Adequate follow-up was available for 108 children with MNE and in this group Initial Success was 49% (ERIC target 50%). 71% were dry at 1 year. There was a dropout rate of 20% in the MNE group (ERIC minimum standard < 25%). We believe the structure of this community based clinic and its approach to MNE management has been successful.

Indications for admission, treatment and improved outcome of paediatric haematology/oncology patients admitted to a tertiary paediatric ICU

BACKGROUND

Overall survival in paediatric cancer has improved significantly over the past 20 years. Treatment strategies have been intensified, and supportive care has made substantial advances. Historically, paediatric oncology patients admitted to an intensive care unit (ICU) have had extremely poor outcomes.

METHODS

We conducted a retrospective cohort study over a 3-year period in a single centre to evaluate the outcomes for this particularly vulnerable group of patients admitted to a paediatric ICU.

RESULTS

Fifty-five patients were admitted a total of 66 times to the ICU during the study period. The mortality rate of this group was 23% compared with an overall ICU mortality rate of 5%. 11/15 patients who died had an underlying haematological malignancy. Twenty-eight percent of children with organism-identified sepsis died.

CONCLUSIONS

While mortality rates for paediatric oncology patients admitted to a ICU have improved, they are still substantial. Those with a haematological malignancy or admitted with sepsis are most at risk.

Professionals delivering palliative care to people with COPD: qualitative study

This article describes health and social care professionals' perceptions of palliative care and facilitators and barriers to the delivery of such care for patients with advanced chronic obstructive pulmonary disease. Health professionals participated in semi structured interviews and focus groups which were analysed using content analysis. According to participants, care of patients with chronic obstructive pulmonary disease is focused upon the management of symptoms, with emphasis focused predominately on an acute model of care. Key barriers towards the delivery of palliative care included the reluctance to negotiatie end-of-life decisions and a perceived lack of understanding among patients and carers regarding the illness trajectory. Consequently the delivery of palliative care was viewed as a specialist role rather than an integral component of care. There is a need for education and training for health and social care professions to plan and provide high quality end-of-life care.

I can not get a breath: experiences of living with advanced chronic obstructive pulmonary disease

This study aims to explore the potential for palliative care among people living with advanced chronic obstructive pulmonary disease (COPD). Individual semi-structured interviews (n=13) were conducted with people who had a diagnosis of advanced COPD and were on optimal tolerated drug therapy, with their breathing volume (forced expiratory volume at less than 30%) or were on long-term oxygen therapy or non-invasion ventilation. Participants raised concerns about the uncertain trajectory of the illness and reported unmet palliative care needs with poor access to palliative care services. For most people, palliative care was associated with end of life; therefore, they were unwilling to discuss the issue. There was a wide acceptance that, medically, nothing more could be done. Findings also suggest that patients had unmet palliative care needs, requiring information and support. The research suggests the need for palliative care to be extended to all (regardless of diagnosis), with packages of care developed to target specific needs.

Dyslipidemia in obese cats

Obesity is an important endocrine disorder in cats and is a risk factor for diabetes similar to humans. The goal of this study was to examine the effect of long-term obesity and different diets (high protein, and high carbohydrate supplemented with saturated fatty acids or n-3 polyunsaturated fatty acids) on plasma lipids in the fasted and fed states in 12 lean (LEAN) and 12 obese (OBESE) cats with ultracentrifugation, and nuclear magnetic resonance spectroscopy. OBESE had higher plasma non-esterified fatty acids and triglycerides, as well as very-low-density-lipoproteins (VLDL) consisting primarily of medium-sized particles. The concentration of low-density-lipoproteins (LDL) was comparable between the groups, although OBESE had mostly very small, whereas LEAN had mostly large particles. The concentration of high-density-lipoproteins (HDL) was lower in OBESE and consisted primarily of small particles. Plasma triglycerides, and triglycerides and cholesterol in all lipoproteins increased postprandially. Different diets had little effect on lipids. Our results show that long-term obese cats develop similar lipoprotein changes to humans, yet, hypertension and atherosclerosis have not been described in obese cats. This suggests that dyslipidemia alone is not sufficient to induce hypertension and atherosclerosis. Other anti-atherogenic factors may be present in the obese, dyslipidemic cat.

Fatty acid turnover, substrate oxidation, and heat production in lean and obese cats during the euglycemic hyperinsulinemic clamp

Simultaneous application of the euglycemic hyperinsulinemic clamp (EHC) and indirect calorimetry was used to examine heat production, fat, and glucose metabolism in lean and obese adult neutered male and female cats. The results show that in lean insulin-sensitive cats glucose oxidation predominated during fasting, whereas lipid oxidation became more prominent in obese cats. Insulin infusion during the EHC in lean cats and obese male cats led to a large increase in glucose oxidation, glycogenesis, and lipogenesis. It also led to an increase in glucose oxidation and glycogenesis in obese female cats but it was significantly less compared to lean cats and obese males. This indicates that obese females show greater metabolic inflexibility. In obese cats of either gender, insulin caused greater suppression of non-esterified fatty acids compared to lean cats suggesting that obese cats show greater fatty acid clearance than lean cats. The heat production per metabolic size was lower in obese cats than lean cats. This would perpetuate obesity unless food intake is decreased. The higher glucose oxidation rate in obese neutered male cats suggests that they are able to replete their glycogen and lipid stores at a faster rate than females in response to insulin and it implies that they gain weight more rapidly. Further studies are needed to investigate if the different response to insulin of male cats is involved in their higher risk to develop diabetes.

Assessment and mathematical modeling of glucose turnover and insulin sensitivity in lean and obese cats

Insulin sensitivity (SI) of glucose disposal can be quantified with the euglycemic hyperinsulinemic clamp (EHC) with tracer glucose infusion. True steady state is, however, difficult to achieve, and non-steady state analysis of EHC data is preferred. This analysis requires information on glucose kinetics that can be obtained from bolus injection of cold and tracer glucose. The aim of this study was to assess glucose kinetics in cats. Mathematical modeling and non-steady state analysis was applied to assess effects of obesity on glucose turnover, glycolysis/glycogen synthesis, SI, and inhibition of endogenous glucose production (EGP) in lean cats (L) and obese cats (O). D-[3-(3)H]-glucose kinetics and 3H-H2O production were analyzed in 4 L and 4 O with three-compartment modeling. Frequently sampled insulin-modified intravenous glucose tolerance tests (FSIGT) with minimal model analysis were performed in 5L and 3 O to assess glucose kinetics and SI. EHC was performed in 10 L and 10 O with primed-constant infusion of 3H-glucose. Data were analyzed with a modified minimal model segregating suppression of EGP by insulin using a non-linear mixed-effects population approach. FSIGT provided estimates of SI, glucose effectiveness SG, and distribution volume. EHC provided estimates of SI, SG, glycolysis, and suprabasal insulin concentration for 50% EGP inhibition. Obesity appears to affect glucose distribution but not utilization at basal insulin, and reduces SI estimated by FSIGT and EHC. Differences in SI between FSIGT and EHC depend on different descriptions of EGP inhibition by insulin. Finally, glucose disposal at basal insulin appears to occur entirely through glycolysis, whereas significant amounts of glucose are sequestrated from oxidation during EHC.

Insulin sensitivity, fat distribution, and adipocytokine response to different diets in lean and obese cats before and after weight loss

Obesity is a major health problem in cats and a risk factor for diabetes. It has been postulated that cats are always gluconeogenic and that the rise in obesity might be related to high dietary carbohydrates. We examined the effect of a high-carbohydrate/low-protein (HC) and a high-protein/low-carbohydrate (HP) diet on glucose and fat metabolism during euglycemic hyperinsulinemic clamp, adipocytokines, and fat distribution in 12 lean and 16 obese cats before and after weight loss. Feeding diet HP led to greater heat production in lean but not in obese cats. Regardless of diet, obese cats had markedly decreased glucose effectiveness and insulin resistance, but greater suppression of nonesterified fatty acids during the euglycemic hyperinsulinemic clamp was seen in obese cats on diet HC compared with lean cats on either diet or obese cats on diet HP. In contrast to humans, obese cats had abdominal fat equally distributed subcutaneously and intra-abdominally. Weight loss normalized insulin sensitivity; however, increased nonesterified fatty acid suppression was maintained and fat loss was less in cats on diet HC. Adiponectin was negatively and leptin positively correlated with fat mass. Lean cats and cats during weight loss, but not obese cats, adapted to the varying dietary carbohydrate/protein content with changes in substrate oxidation. We conclude that diet HP is beneficial through maintenance of normal insulin sensitivity of fat metabolism in obese cats, facilitating the loss of fat during weight loss, and increasing heat production in lean cats. These data also show that insulin sensitivity of glucose and fat metabolism can be differentially regulated in cats.

Genetic conditions in the Irish Roma gypsy population

Roma gypsy represent a new Irish ethnic minority population with a distinct cultural and racial heritage. There is a strong Roma tradition of consanguinity, which can increase the likelihood of having a child affected by an autosomal recessive disorder. We describe 6 patients from the Roma community who had presented with 4 different autosomal recessive conditions not previously seen in the Irish population, Chronic Granulomatous Disease, HMSN-Russe, and two multiple malformation syndromes.

Training and manpower issues for specialist registrars in paediatrics. How are we doing and where are we going?

All Irish paediatric higher specialist trainees' opinions about the paediatric higher specialist training (HST) scheme and related manpower issues were surveyed. Information was obtained on 1) trainees' level of satisfaction with HST, 2) their ultimate career ambitions including location of final posts, 3) attitudes to both flexible training and consultancies and 4) demographics to assess the significance of gender variations. Fifty-two eligible trainees were identified using the Royal College of Physicians of Ireland database. The survey was administered as an anonymous postal survey. The response rate was 88%. Results indicated a high level of satisfaction with HST (78%) overall although problems were noted with the half-day release programme as only 63% were facilitated. Only 30% wish to practice as subspecialists, 76% of trainees wish to work in an urban hospital and 43.5% desire a flexible consultancy suggesting an incompatibility of trainees' desires with current Irish medical manpower policy. To address these difficulties we suggest establishing more rigorous audit of training posts to ensure deficiencies are corrected and the establishment of flexible training to address gender imbalance and to promote the concept of consultant job sharing.

The MELAS syndrome. Review of the literature: the role of the otologist

The mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome is a rare congenital disorder of mitochondrial DNA (mt-DNA). Patients with this syndrome may present to the otolaryngologist with sensorineural hearing loss (SNHL), which is genetic in origin. A high index of suspicion is required because this hearing loss is part of a syndrome for which early diagnosis and intervention is required.

An ALS-like syndrome with new HIV infection and complete response to antiretroviral therapy

A 32-year-old woman presenting with a rapidly progressive ALS-like syndrome was found to be HIV positive with a CD4 count of 44/mm(3). The patient recovered completely during 1 year after treatment with nelfinavir, zidovudine, and lamivudine, and recovery is sustained nearly 4 years later. Recovery was accompanied by HIV RNA becoming undetectable in plasma and CSF.

Nonshared environment: a theoretical, methodological, and quantitative review

When genetic similarity is controlled, siblings often appear no more alike than individuals selected at random from the population. Since R. Plomin and D. Daniels' seminal 1987 review, it has become widely accepted that the source of this dissimilarity is a variance component called nonshared environment. The authors review the conceptual foundations of nonshared environment, with emphasis on distinctions between components of environmental variance and causal properties of environmental events and between the effective and objective aspects of the environment. A statistical model of shared and nonshared environmental variables is developed. A quantitative review shows that measured nonshared environmental variables do not account for a substantial portion of the nonshared variability posited by biometric studies of behavior. Other explanations of the preponderance of nonshared environmental variability are suggested.

Nonshared environment: a theoretical, methodological, and quantitative review

When genetic similarity is controlled, siblings often appear no more alike than individuals selected at random from the population. Since R. Plomin and D. Daniels' seminal 1987 review, it has become widely accepted that the source of this dissimilarity is a variance component called nonshared environment. The authors review the conceptual foundations of nonshared environment, with emphasis on distinctions between components of environmental variance and causal properties of environmental events and between the effective and objective aspects of the environment. A statistical model of shared and nonshared environmental variables is developed. A quantitative review shows that measured nonshared environmental variables do not account for a substantial portion of the nonshared variability posited by biometric studies of behavior. Other explanations of the preponderance of nonshared environmental variability are suggested.

Early-onset chronic renal failure as a presentation of infantile nephropathic cystinosis

We report an 18-month-old girl who presented in chronic renal failure after an illness characterised by protracted diarrhoea, poor weight gain and anaemia. There were no symptoms and signs suggestive of a renal Fanconi syndrome, but a diagnosis of nephropathic cystinosis was suggested by renal biopsy and confirmed by an elevated leucocyte cystine concentration. We suggest that the diagnosis of cystinosis should be considered in any child with chronic renal failure of unknown aetiology.

Respiratory disease in pregnancy

Respiratory disease is common in pregnancy, and becoming more so: asthma, pneumonia and tuberculosis are all increasing in frequency. This review discusses these conditions and their relationship to pregnancy, as well as considering briefly some rarer diseases.

Oculocerebral hypopigmentation syndrome associated with Bartter syndrome

We describe a 20-year-old man with tyrosinase-negative oculocutaneous albinism, mental retardation, epilepsy, sensorineural deafness, ataxia, and Bartter syndrome. When combined, these neurocutaneous and renal findings form a previously unreported combination. The neurological and cutaneous manifestations of this case are distinctly different from those of the syndrome first reported by Cross et al. [1967]. The literature is reviewed and an attempt is made at classifying the oculocerebral hypopigmentation syndromes.

Intraglomerular foam cells and human focal glomerulosclerosis

Experimental evidence suggests a pathogenetic role for lipids in focal glomerulosclerosis (FGS) analogous to atherosclerosis. As foam cells (FC) are an important factor in atherosclerosis, a retrospective comparative study was done to evaluate the significance of intraglomerular FC in human FGS. Glomerular FC infiltration was evaluated in 115 biopsies of FGS, 120 biopsies of membranous glomerulonephritis (MGN) and 50 biopsies of minimal-change disease (MCD). Selected clinical and laboratory data collected at about the time of biopsy were reviewed. The proportion of biopsies showing glomerular FC was much higher in FGS (70%) than in either MGN (12%) or MCD (0%) p less than 0.001. The mean percent (+/- SD) of glomeruli with FC per biopsy was significantly greater in FGS (7.9 +/- 9.9) than in MGN (2.0 +/- 7.8; p less than 0.0001). Of the 14 MGN biopsies with FC, 13 showed superimposed FGS. Mean serum total cholesterol and triglyceride were not significantly higher in FGS than in either MGN or MCD. The results demonstrate a close association of glomerular FC infiltration with FGS.

Combined endoscopic cytology and biopsies in the diagnosis of duodenal malignancy

The value of combined cytohistochemical examination in the diagnosis of malignant duodenal lesions was assessed in 78 patients with suspicious duodenal lesions seen at endoscopy. Cytological smears were taken using the direct-vision brushing technique and all were processed by the same experienced cytologist. Duodenal malignancy was confirmed histologically in four patients. Endoscopic biopsy was positive for malignancy in three of the patients and cytology was suspicious of malignant change in two patients and positive for malignant change in one patient. Cytology alone confirmed the diagnosis of malignancy in one patient. The cumulative diagnostic yield using both biopsy and cytology was 100%.

Early history of parenteral nutrition

A historical review is presented of a number of aspects of early animal experiments and clinical trials dealing with the i.v. infusion of whole blood and milk; the nutritional use of i.v. erythrocytes, plasma proteins, protein hydrolysates, amino acids, and glucose; and development and use of i.v. fat emulsions. A brief description of the experience with the nutritional use of i.v. ethyl alcohol is also presented. The important studies beginning in the 1960's by Dudrick, Rhoads, Vars, and Wilmore are described elsewhere by them.

Measuring creativity through computer graphics of hearing-impaired children

The purpose of this study was to investigate variables affecting visual creativity of 31 hearing-impaired children through the medium of computer graphics. These children ranged in age from 8.0 to 15.9 yr. 16 subjects attended total-communication educational programs and 15 subjects attended aural/oral classes. Each subject worked independently at a computer terminal equipped with a graphics menu developed for a subject's use. Hardcopy printouts of four images per subject were evaluated for creativity, aesthetics, and imagery. Analysis suggested that creativity among hearing-impaired children is influenced by age and communication mode used in the educational setting.