Maternal and cord plasma branched-chain amino acids and child risk of attention-deficit hyperactivity disorder: a prospective birth cohort study

BACKGROUND

Branched-chain amino acids (BCAA: leucine, isoleucine, and valine) are essential amino acids involved in biological functions of brain development and recently linked with autism. However, their role in attention-deficit hyperactivity disorder (ADHD) is not well-studied. We investigated individual and combined relationships of maternal plasma and newborn cord plasma BCAAs with childhood development of ADHD.

METHODS

We utilized the Boston Birth Cohort, a predominantly urban, low-income, US minority population. Child developmental outcomes were defined in three mutually exclusive groups - ADHD, neurotypical (NT), or other developmental disabilities based on physician diagnoses per ICD-9 or 10 in medical records. The final sample included 626 children (299 ADHD, 327 NT) excluding other developmental disabilities. BCAAs were measured by liquid chromatography-tandem mass spectrometry. We used factor analysis to create composite scores of maternal and cord BCAA, which we divided into tertiles. Logistic regressions analyzed relationships between maternal or cord BCAA tertiles with child ADHD risk, controlling for maternal race, age, parity, smoking, education, low birth weight, preterm birth, and child sex. Additionally, we analyzed maternal and cord plasma BCAAs jointly on child ADHD risk.

RESULTS

Adjusted logistic regression found significantly increased odds of child ADHD diagnosis for the second (OR 1.63, 95% CI: 1.04, 2.54, p = .032) and third tertiles (OR 2.01, 95% CI: 1.28, 3.15, p = .002) of cord BCAA scores compared to the first tertile. This finding held for the third tertile when further adjusting for maternal BCAA score. There was no significant association between maternal BCAA score and child ADHD risk, nor a significant interaction between maternal and cord BCAA scores.

CONCLUSIONS

In this prospective US birth cohort, higher cord BCAA levels were associated with a greater risk of developing ADHD in childhood. These results have implications for further research into mechanisms of ADHD development and possible early life screening and interventions.

Injury incidence and locomotor behaviours in polocrosse ponies

There is currently limited information available regarding the physical demands of polocrosse and no information on the specific veterinary problems faced by polocrosse ponies in the United Kingdom. Polocrosse requires the ponies that compete to perform rapid acceleration, sharp turns and sudden halts. The study aim was to explore the injury incidence and type of injury, between the three positions played by polocrosse ponies. Injuries that resulted in withdrawal of a pony during outdoor tournaments in the UK over the 2015 and 2016 seasons were recorded. In addition, GPS data and locomotor behaviours were recorded during winter league tournaments in 2017 and compared between the different position ponies. Ponies that played in the defence position were significantly more likely to become injured (P<0.001) with lameness being the most common cause for withdrawal (P<0.001). Ponies playing in the attack position achieved the fastest speeds and covered the furthest distance. Defence ponies performed significantly more abrupt halts (P=0.007), walk to gallop transitions (P=0.017) and sudden changes in direction (P=0.01) than midfield ponies and more of each manoeuvre than attack ponies, although this was not significant. It is important that the physical demands placed upon polocrosse ponies are investigated further; this will allow identification of injury risk factors, inform training programmes and improve the performance and welfare of the horses involved.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Association of Cord Plasma Biomarkers of In Utero Acetaminophen Exposure With Risk of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in Childhood

IMPORTANCE

Prior studies have raised concern about maternal acetaminophen use during pregnancy and increased risk of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in their children; however, most studies have relied on maternal self-report.

OBJECTIVE

To examine the prospective associations between cord plasma acetaminophen metabolites and physician-diagnosed ADHD, ASD, both ADHD and ASD, and developmental disabilities (DDs) in childhood.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study analyzed 996 mother-infant dyads, a subset of the Boston Birth Cohort, who were enrolled at birth and followed up prospectively at the Boston Medical Center from October 1, 1998, to June 30, 2018.

EXPOSURES

Three cord acetaminophen metabolites (unchanged acetaminophen, acetaminophen glucuronide, and 3-[N-acetyl-l-cystein-S-yl]-acetaminophen) were measured in archived cord plasma samples collected at birth.

MAIN OUTCOMES AND MEASURES

Physician-diagnosed ADHD, ASD, and other DDs as documented in the child's medical records.

RESULTS

Of 996 participants (mean [SD] age, 9.8 [3.9] years; 548 [55.0%] male), the final sample included 257 children (25.8%) with ADHD only, 66 (6.6%) with ASD only, 42 (4.2%) with both ADHD and ASD, 304 (30.5%) with other DDs, and 327 (32.8%) who were neurotypical. Unchanged acetaminophen levels were detectable in all cord plasma samples. Compared with being in the first tertile, being in the second and third tertiles of cord acetaminophen burden was associated with higher odds of ADHD diagnosis (odds ratio [OR] for second tertile, 2.26; 95% CI, 1.40-3.69; OR for third tertile, 2.86; 95% CI, 1.77-4.67) and ASD diagnosis (OR for second tertile, 2.14; 95% CI, 0.93-5.13; OR for third tertile, 3.62; 95% CI, 1.62-8.60). Sensitivity analyses and subgroup analyses found consistent associations between acetaminophen buden and ADHD and acetaminophen burden and ASD across strata of potential confounders, including maternal indication, substance use, preterm birth, and child age and sex, for which point estimates for the ORs vary from 2.3 to 3.5 for ADHD and 1.6 to 4.1 for ASD.

CONCLUSIONS AND RELEVANCE

Cord biomarkers of fetal exposure to acetaminophen were associated with significantly increased risk of childhood ADHD and ASD in a dose-response fashion. Our findings support previous studies regarding the association between prenatal and perinatal acetaminophen exposure and childhood neurodevelopmental risk and warrant additional investigations.

Developmental cascades of social competence, achievement in school, and achievement on standardized assessments during the transition to adolescence and secondary school

INTRODUCTION

Social and academic functioning are cornerstones of positive youth development and important to later educational and health outcomes. Yet, little is known about how the timing and direction of relationships between social and academic functioning vary by the type of achievement assessed and how the transition to adolescence influences these relationships.

METHOD

This study employs longitudinal structural equation modeling to examine the interrelationships of children's social competence, teacher ratings of school achievement, and standardized assessments of cognitive achievement in a cohort of 1048 children in the United States.

RESULTS

& Conclusions: Results identify 1) direct and indirect pathways from children's social competence in grades three and five to their school achievement in grades five and six; 2) significant pathways between school and cognitive achievement across all assessment points that decline in magnitude as students enter high school; 3) the magnitude of pathways between social competence and school achievement far exceed those between social competence and cognitive achievement; and 4) social and maturational factors account for variation in these functions but do not confound the timing and direction of the pathways from one to the other function. Given the importance of social competence and academic achievement to positive development, these findings demonstrate elementary school as an optimal and foundational period to implement universal interventions to optimize social functioning and prevent later academic difficulties in secondary school.

Differential Effects of Weight Status on the Relations Between Diet Quality, Socioemotional Development, and Academic Performance in U.S. Schoolchildren (P14-008-19)

Objectives

Child obesity, a risk factor for adverse health and functioning, can foster a heightened stress state in the body that may affect relations between nutritional status and cognitive development. We investigated if associations between diet quality (DQ), socioemotional development (SED), and academic performance (AP) varied by child weight status in U.S. 5th graders.

Methods

Nationally representative data from 7755 U.S. children (mean age 11–11.5 years) were analyzed using survey-weighted, multiple linear regression models adjusted for relevant factors. DQ was calculated by applying a novel short Diet Quality Index (sDQI) on a brief food frequency questionnaire. Established measures for SED (Self-Description Questionnaire scaled scores for internalizing and externalizing problem behaviors [IPB, EPB] and peer relations competency) and AP (standardized reading, math, and science test scores) served as dependent variables. Children's weight status was classified based on their BMI compared against sex-age-specific BMI percentiles of CDC Child Growth Charts.

Results

Some relations between DQ and SED and AP were slightly moderated by child weight status. A borderline significant interaction between DQ and IPB (overall F = 2.48; P = 0.06) revealed better socioemotional health with higher diet quality for both underweight (β = −0.02 [SE = 0.01]; P < 0.01) and overweight children (β = −0.01 [SE = 0.00]; P = 0.01) that was not observed in children of normal weight (β = −0.00 [SE = 0.00]; P = 0.07) or obese (β = −0.01 [SE = 0.00]; P = 0.16) status. Another borderline significant interaction between DQ and math scores (overall F = 2.39; P = 0.07) highlighted higher scores with higher diet quality in underweight (β = 0.18 [SE = 0.07]; P = 0.01) and normal weight children (β = 0.10 [SE = 0.02]; P < 0.01) not observed in overweight (β = 0.00 [SE = 0.04]; P = 0.96) or obese (β = 0.02 [SE = 0.05]; P = 0.75) children. Significant interactions were not observed between DQ and EPB or peer relation competency, or DQ and reading or science scores, by child weight status.

Conclusions

The moderating effects of child weight status here underscore a need for more research on the stress of malnutrition (non-normal weight status) in child development. Interventions to improve cognitive health through diet should heed underlying vulnerabilities within population groups to optimize success.

Funding Sources

n/a.

Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US

BACKGROUND

Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide.

METHODS

ED data came from the 2011-2015 National Hospital Ambulatory Medical Care Survey, a national survey of ED visits across the United States. Psychiatric ED visits were identified by using the International Classification of Diseases, Ninth Revision and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates.

RESULTS

Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6-11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit.

CONCLUSIONS

Visits to the ED for psychiatric purposes among youth are rising across the United States. Psychiatric expertise and effective mental health treatment options, particular those used to address the rising suicide epidemic among adolescents, are needed in the ED.

Low-Income Urban Mothers' Experiences with the Supplemental Nutrition Assistance Program

BACKGROUND

Food insecurity remains a public health concern in the United States, particularly among low-income urban ethnically diverse families, even with the Supplemental Nutrition Assistance Program (SNAP). Limited phenomenologic data exist to capture how programmatic changes to SNAP address the needs of users and why a gap in SNAP use may exist.

OBJECTIVE

The primary aim of this study was to examine the experiences of low-income, Baltimore, MD, mothers in applying for and maintaining access to SNAP. Secondary aims included understanding participants' perspectives on the influence of changes in SNAP over a 3-year period and how SNAP fits into the overall system of social services for families.

DESIGN

In this qualitative, phenomenologic study, in-depth interviews were conducted with 13 mothers and three focus groups with 20 mothers, for a total sample of 33 mothers receiving SNAP benefits. Ten mothers participated in the first round of data collection (January to May 2010), and 23 in the second round (February to May 2013).

PARTICIPANTS/SETTING

Participants were 33 mothers receiving SNAP benefits in Baltimore City, MD.

MAIN OUTCOME MEASURES

Baltimore SNAP users' experiences with applying for and maintaining access to SNAP, as well as with program changes to the SNAP program.

DATA ANALYSIS

Data were analyzed using an iterative emergent design and phenomenologic approach. A constructivist perspective was implemented throughout the coding process.

RESULTS

SNAP functioned as a valuable support system within the broader social safety net for mothers living in poverty, yet participants expressed frustration about the processes of applying for and maintaining benefits due to communication problems and poor integration of services. In applying for and accessing SNAP, positive interactions with caseworkers and previous knowledge of the SNAP program were important for maintaining benefits. Interviews and focus group discussions revealed the need for additional outreach and education about the implemented program changes to build trust and improve access to SNAP among participants.

CONCLUSIONS

Improving communication and supporting participants' ability to maintain relationships with the same caseworkers, as well as developing better integration with other aid programs, could improve the SNAP program.

The Association of Maternal Obesity and Diabetes With Autism and Other Developmental Disabilities

BACKGROUND

Obesity and diabetes are highly prevalent among pregnant women in the United States. No study has examined the independent and combined effects of maternal prepregnancy obesity and maternal diabetes on the risk of autism spectrum disorder (ASD) in parallel with other developmental disorders (DDs).

METHODS

This study is based on 2734 children (including 102 ASD cases), a subset of the Boston Birth Cohort who completed at least 1 postnatal study visit at Boston Medical Center between 1998 and 2014. Child ASD and other DDs were based on physician diagnoses as documented in electronic medical records. Risks of ASD and other DDs were compared among 6 groups defined by maternal prepregnancy obesity and diabetes status by using Cox proportional hazard regression controlling for potential confounders.

RESULTS

When examined individually, maternal prepregnancy obesity and pregestational diabetes (PGDM) were each associated with risk of ASD. When examined in combination, only mothers with obesity and PGDM (hazard ratio 3.91, 95% confidence interval 1.76-8.68) and those with obesity and gestational diabetes (hazard ratio 3.04, 95% confidence interval 1.21-7.63) had a significantly increased risk of offspring ASD. Intellectual disabilities (IDs), but not other DDs, showed a similar pattern of increased risk associated with combined obesity and PGDM. This pattern of risk was mostly accounted for by cases with co-occurring ASD and ID.

CONCLUSIONS

Maternal prepregnancy obesity and maternal diabetes in combination were associated with increased risk for ASD and ID. ASD with ID may be etiologically distinct from ASD without ID.

Quantification of eggshell microstructure using X-ray micro computed tomography

1. X-ray microcomputed tomography can be used to produce rapid, fully analysable, three-dimensional images of biological and other materials without the need for complex or tedious sample preparation and sectioning. We describe the use of this technique to visualise and analyse the microstructure of fragments of shell taken from three regions of chicken eggs (sharp pole, blunt pole and equatorial region).

2. Two- and three-dimensional images and data were obtained at a resolution of 1.5 microns. The images were analysed to provide measurements of shell thickness, the spacial density of mammillary bodies, the frequency, shape, volume and effective diameter of individual pore spaces, and the intrinsic sponginess (proportion of non-X-ray dense material formed by vesicles) of the shell matrix. Measurements of these parameters were comparable with those derived by traditional methods and reported in the literature.

3. The advantages of using this technology for the quantification of eggshell microstructural parameters and its potential application for commercial, research and other purposes are discussed.

Health and well-being in adolescent survivors of early childhood cancer: a report from the Childhood Cancer Survivor Study

OBJECTIVE

With the growing number of childhood cancer survivors in the US, it is important to assess the well-being of these individuals, particularly during the transitional phase of adolescence. Data about adolescent survivors' overall health and quality of life will help identify survivor subgroups most in need of targeted attention to successfully transition to adulthood.

PARTICIPANTS AND METHODS

This ancillary study to the Childhood Cancer Survivor Study focused on children 15-19 years of age who had been diagnosed with cancer before the age of 4 years. A cohort of siblings of pediatric cancer survivors of the same ages served as a comparison sample. Adolescent health was assessed using the Child Health and Illness Profile-Adolescent Edition (CHIP-AE) survey.

RESULTS

The teen survey was sent to 444 survivor teens and 189 siblings. Of these, 307(69%) survivors and 97 (51%) siblings completed and returned the survey. The overall health profiles of siblings and survivors were similar. Among survivors, females scored significantly below males on satisfaction, discomfort, and disorders domains. Survivors diagnosed with central nervous system tumors scored less favorably than leukemia survivors in the global domains of satisfaction and disorders.

CONCLUSION

In general, adolescent survivors fare favorably compared to healthy siblings. However, identification of the subset of pediatric cancer survivors who are more vulnerable to medical and psychosocial disorders in adolescence provides the opportunity for design and implementation of intervention strategies that may improve quality of life.

Effects on children of treating their mothers' depression: results of a 12-month follow-up

OBJECTIVE

This study used a controlled research design to examine the effects on children of treating their mothers' depression and of remission of the mothers' depression.

METHOD

The sample consisted of 60 low-income women with major depression, who were predominantly from minority racial-ethnic groups, and their children ages four to 11. Women were randomly assigned to receive one of two active treatments (medication or cognitive-behavioral therapy) or a referral to existing community services. The mothers' depression was assessed by self-report on the Hamilton Depression Rating Scale, and the children's symptoms and adaptive skills were assessed by their mothers at baseline and six-month and 12-month follow-ups with the Behavior Assessment System for Children.

RESULTS

Mixed-effects random intercept and random slope repeated-measures analyses using an intent-to-treat approach indicated that active treatment of mothers did not result in improvement in their children's behavior problems or adaptive skills. However, at both the six- and the 12-month follow-ups, children of mothers whose depression had remitted, regardless of treatment assignment, had significantly fewer behavior problems than children whose mothers remained depressed.

CONCLUSIONS

The results support the need to expand access to, and support participation in, depression treatment among low-income women from minority racial-ethnic groups. Although treatment alone of this undertreated population was not associated with improvement in children's outcomes, it is a necessary first step to prevent psychopathology among offspring of depressed parents.

Extending the clinical research network approach to all of healthcare

The development of Clinical Research Networks (CRN) has been central to the work conducted by Health Departments and research funders to promote and support clinical research within the NHS in the UK. In England, the National Institute for Health Research has supported the delivery of clinical research within the NHS primarily through CRN. CRN provide the essential infrastructure within the NHS for the set up and delivery of clinical research within a high-quality peer-reviewed portfolio of studies. The success of the National Cancer Research Network is summarized in Chapter 5. In this chapter progress in five other topics, and more recently in primary care and comprehensively across the NHS, is summarized. In each of the 'topic-specific' networks (Dementias and Neurodegenerative Diseases, Diabetes, Medicines for Children, Mental Health, Stroke) there has been a rapid and substantial increase in portfolios and in the recruitment of patients into studies in these portfolios. The processes and the key success factors are described. The CRN have worked to support research supported by pharmaceutical, biotechnology and medical device companies and there has been substantial progress in improving the speed, cost and delivery of these 'industry' studies. In particular, work to support the increased speed of set up and delivery of industry studies, and to embed this firmly in the NHS, was explored in the North West of England in an Exemplar Programme which showed substantial reductions in study set-up times and improved recruitment into studies and showed how healthcare (NHS) organizations can overcome delays in set up times when they actively manage the process. Seven out of 20 international studies reported that the first patient to be entered anywhere in the world was from the UK. In addition, the CRN have supported research management and governance, workforce development and clinical trials unit collaboration and coordination. International peer reviews of all of the CRN have been positive and resulted in the continuation of the system for a further 5 years in all cases.

Children's reports of activity and participation after sustaining a spinal cord injury: a cognitive interviewing study

OBJECTIVE

To evaluate the readability, comprehension and response processes of test items designed to measure activity performance and participation by children with spinal cord injury (SCI).

METHODS

Eleven parents and 33 children participated. Descriptive statistics were used to calculate frequency of problems based on age, grade, domain and response scale. Agreement was evaluated by weighted kappa coefficient values.

RESULTS

Most (54%) of the problems were due to reading/comprehension, with the majority by children 8 years of age or younger (56%) who had not completed 2nd grade (51%). Agreement between child-parent reports ranged from poor-good, with strongest agreement for mobility items and weak agreement for chores, self-care and participation.

CONCLUSION

Children with SCI 8 years of age and older who have competed 2nd grade are able to read, understand and respond to items associated with activity performance and participation.

Patterns of switching phosphodiesterase type 5 inhibitors in the treatment of erectile dysfunction: results from the Erectile Dysfunction Observational Study

AIMS

This report describes patterns of treatment changes with the phosphodiesterase type 5 (PDE5) inhibitors tadalafil, sildenafil and vardenafil, and variables associated with those treatment changes, during the 6-month, prospective, pan-European Erectile Dysfunction Observational Study (EDOS).

METHODS

EDOS observed 8047 men > or = 18 years old with erectile dysfunction (ED), who began or changed ED therapy as part of their routine healthcare. Patients could change ED treatment at any time during EDOS. Data were collected at baseline and at 3 (+/- 1) and 6 (+/- 1) months. Analyses included ED treatment-naïve patients with complete follow-up who were prescribed a PDE5 inhibitor at baseline (n = 4026).

RESULTS

Most patients, regardless of what PDE5 inhibitor they were prescribed at baseline, continued on that same PDE5 inhibitor throughout the study. Continuation rates were approximately 89% in the tadalafil cohort, vs. 63-64% in the sildenafil and vardenafil cohorts. The variables most strongly associated with increased risk of switching were prescription of sildenafil or vardenafil, vs. tadalafil, at baseline (odds ratios 4.43 and 4.14 respectively; p < 0.0001). Of patients who switched from tadalafil to another treatment, nearly 25% had switched back to tadalafil by study end. In contrast, of patients who switched from sildenafil or vardenafil, < 10% from each cohort had switched back to their original treatment by study end.

CONCLUSION

The data suggest that tadalafil treatment in treatment-naïve ED patients may increase their likelihood of treatment continuation. These findings should be interpreted conservatively due to the observational nature of the study.

Development of a Communicative Performance Scale for Pediatric Cochlear Implantation

OBJECTIVE

Verbal communicative competence is the main objective after early cochlear implantation in deaf children. However, there are currently no validated instruments to assess a child's real-world communicative abilities. We adopted a rigorous methodological approach to systematically develop the Functioning after Pediatric Cochlear Implantation instrument (FAPCI), a family-centered communicative performance scale based on a conceptual model of functioning established by the World Health Organization.

DESIGN

Qualitative instrument development was based on a systematic review of the literature, focus groups, and semistructured interviews with the parents of 2- to 5-yr-old children with cochlear implants and deafness experts. Further refinement and testing of the psychometric validity of the draft instrument was conducted using factor analysis and a cross-sectional sample of 75 parents of children with cochlear implants. Nonparametric and parametric regressions were then performed to investigate the association of FAPCI scores with duration of cochlear implant use to provide preliminary evidence for the instrument's nomological validity.

RESULTS

The final 23-item, parent-proxy FAPCI instrument represents a unidimensional scale of the real-world communicative performance of 2- to 5-yr-old children with cochlear implants. The scale demonstrated excellent reliability (Cronbach's alpha >or=0.86), and there was strong evidence supporting the instrument's nomological validity. FAPCI scores were positively associated with duration of implant use (p < .001), and 4 yr of implant use were required before maximal FAPCI scores were achieved.

CONCLUSIONS

Verbal communication is a critical developmental domain that allows for optimal future emotional, cognitive, and behavioral growth. The FAPCI instrument is the first validated instrument ever designed to assess real-world communicative performance of a child with a cochlear implant. The systematic approach taken to development may enable FAPCI to be sensitive to other communication-related disorders commonly seen in childhood or to serve as a model for the development of other disorder-specific instruments.

Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana

PROBLEM

As programmes to deliver antiretroviral therapy (ART) are implemented in resource-constrained settings, the problem becomes not how these programmes are going to be financed but who will be responsible for delivering and sustaining them.

APPROACH

Physician-led models of HIV treatment and care that have evolved in industrialized countries are not replicable in settings with a high prevalence of HIV infection and limited access to medical staff. Therefore, models of care need to make better use of available human resources.

LOCAL SETTING

Using Botswana as an example, we discuss how nurses are underutilized in long-term clinical management of patients requiring ART.

RELEVANT CHANGES

We argue that for ART-delivery programmes to be sustainable, nurses will need to provide a level of clinical care for patients receiving this therapy, including prescribing ART and managing common adverse effects.

LESSONS LEARNED

Practicalities involved in scaling up nurse-led models of ART delivery include overcoming political and professional barriers, identifying educational requirements, agreeing on the limitations of nursing practice, developing clear referral pathways between medical and nursing personnel, and developing mechanisms to monitor and supervise practice. Operational research is required to demonstrate that such models are safe, effective and sustainable.

Treatment of premature ejaculation

Premature ejaculation (PE) is a common problem, the treatment of which has received an increasing interest in recent years. Traditional management continues to be psychotherapy, with techniques such as the 'squeeze' and 'stop-start' most commonly employed. The application of local anaesthetics to the glans to delay ejaculation, first described over 60 years ago, continues to be used both in medical practice and as an 'over-the-counter' remedy. Over the years, a variety of psychopharmacological agents, especially antidepressants, have been described as treatments for PE. At the present time, the selective serotonin re-uptake inhibitors, licensed for other indications, emerge as the most effective agents to delay ejaculation, but none are licensed for the treatment of PE. There appears to be a high relapse rate irrespective of the mode of therapy used.

Premature ejaculation: presentation and associations. An audit of patients attending a sexual problems clinic

The diagnostic register and case summaries of all male and female patients who attended the clinic on account of one or more sexual symptoms or relationship problems between 1 January 1992 and 31 December 1997 were reviewed. The index symptom or problem was considered the complaint that caused the patient most concern. When patients or couples were experiencing more than one sexual problem, the concomitant problems were tabulated against the index symptom. During this period, 1,056 (440 men and 616 women) patients with sexual symptoms were seen and 131 couples attended primarily with relationship problems. Overall, 18.2% of men referred to the clinic with sexual problems had premature ejaculation (PE), but this was the index symptom in only 11.6% of men. There was a high occurrence of PE in the partners of women presenting with sexual symptoms. Among couples presenting with relationship dissatisfaction or conflict, 18.3% of the male partners had ongoing PE.

Assessing Health Status and Health Care Utilization in Adolescents with Chronic Kidney Disease

Few validated health status measures have been assessed in children with chronic kidney disease (CKD). The objective was to assess the validity of a generic health status measure, the Child Health and Illness Profile-Adolescent Edition (CHIP-AE), in adolescents with CKD. A case-control study was performed (1) to assess scores on the CHIP-AE in adolescents with CKD compared with two control groups of age-, socioeconomic-, and gender-matched peers and (2) to compare health of patients who had chronic renal insufficiency (CRI), were on dialysis, and were posttransplantation. Seven pediatric nephrology centers recruited 113 patients (mean age, 14 yr; 39 CRI, 21 dialysis, 53 posttransplantation). Compared with 226 control subjects, patients with CKD had lower overall satisfaction with health and more restriction in activity. Positively, patients with CKD had more family involvement, better home safety and health practices, and better social problem-solving skills and were less likely to participate in risky social behaviors or socialize with peers who engaged in risky behavior. Patients who received dialysis were less physically active and experienced more physical discomfort and limitations in activities than did transplant or CRI patients. It is concluded that patients with CKD have poorer functional health status than age-matched peers. Among CKD patients, dialysis patients have the poorest functional health status. These results suggest that the CHIP-AE can be used to measure functional health status in adolescent patients with CKD.

Versión española del perfil de salud infantil, cuestionario para padres y madres: Child Health and Illness Profile-Child Edition Parent Report Form (CHIP-CE/PRF)

OBJECTIVES

To analyze the reliability and validity of the domains of the Child Health and Illness Profile-Child Edition Parent Report Form (CHIP-CE/PRF) included in the Barcelona Health Survey conducted in 2000 and to obtain population-based reference values.

METHODS

Data were obtained from proxy-respondent interviews of children aged 5-14 years old (n = 836) participating in the Barcelona Health Survey 2000. The 4 subdomains of the parent version of the CHIP-PRF included in the health survey were: satisfaction with health, and physical discomfort, emotional discomfort, and limitation of activities of the discomfort domain. Internal consistency was assessed using Cronbach's alpha coefficients. An exploratory factor analysis was carried out and analysis of covariance was performed to assess the construct validity of the subdomains.

RESULTS

In all the subdomains assessed, Cronbach's alpha was above 0.70 (range, 0.76-0.98). In the factorial analysis, almost all the items (31/35) presented the highest load in their corresponding subdomain. Most of the expected mean differences among groups were confirmed. Girls aged 10-14 years old scored the lowest, both in satisfaction with health (48.93; 95% confidence interval [CI 95%], 47.40-50.47) and in discomfort (48.87; CI 95%, 47.51-50.22). No differences were found according to the social class of the head of the family.

CONCLUSIONS

The present study provides a useful measure of perceived health status in a child health survey.

Adaptación de la versión española del Perfil de Salud Infantil (Child Health and Illness Profile-Child Edition, CHIP-CE)

OBJECTIVES

To obtain a Spanish version of the CHIP-CE semantically and culturally equivalent to the original version.

METHOD

The methodology used was based on the forward-backward method. Two translations into Spanish were performed. After the first reconciled version, 44 cognitive interviews were carried out with children aged 6-11 years old, selected from two schools in Barcelona. The interviews were recorded and transcribed. A qualitative content analysis of the textual data was carried out. A panel of experts developed the second reconciled version taking into account the children's comments. A back-translation into English was carried out and was compared with the original version.

RESULTS

Of a total of 45 items induced in the first reconciled version, 21 were considered equivalent, 23 required changes and 1 was considered not equivalent. Comprehension of abstract concepts differed according to age. Older children differentiated among concepts and gave different examples of experiences related to these concepts, while younger children (6 to 7-year olds) provided similar examples for different concepts. The children's comments were used in the reformulation of the items. An illustrative figure reinforced understanding. Children aged 7 or more started to use an adequate recall period and used the response options correctly.

CONCLUSIONS

The Spanish version of the CHIP-CE seems appropriate for children aged 6-11 in Spain. The present study shows that children from the age of 6 years onwards are able to describe the health concepts included in the CHIP-CE.

Validity of the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE)

OBJECTIVES

To assess the structural, convergent, discriminant, and criterion validity of the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE) and to compare results with the U.S. version.

SUBJECTS

A sample of adolescents aged 12 to 19 attending schools and representative of the school-aged population in Barcelona, Spain (n = 902).

MEASURES

Exploratory factor analyses were performed, and results compared with the U.S. version. The Child Depression Inventory (CDI) and the State-Trait Anxiety Inventory (STAIC) were administered to a subgroup of adolescents to assess convergent and discriminant validity. Criterion validity was assessed by using receiver operating characteristic (ROC) curves to examine the ability of the CHIP-AE academic performance subdomain to predict school grades.

RESULTS

The Spanish version has 6 defined domains with a factor structure showing minor differences from the U.S. version. Higher correlations were found between the CDI and STAIC and CHIP-AE subdomains of emotional discomfort and self-esteem (range. 0.48-0.80, P<0.01) than with scales measuring dissimilar concepts. The area under the ROC curve was 0.83 (95% confidence interval, 0.75-0.92) for the number of failed subjects (none/one or more) related to academic performance.

CONCLUSIONS

The underlying theoretical model of the Spanish version of the CHIP-AE functions well in Spain, and the Spanish version has acceptable levels of convergent, discriminant, and criterion validity. Sensitivity to change and the use of the health profiles need to be assessed.

Timing of menopause and patterns of menstrual bleeding

Age at menopause is associated with a variety of health outcomes. Menstrual histories, both as markers of physiologic function and through their potential association with age at menopause, have also been investigated for their links to health outcomes. This study used data from a cohort of women from the United States who provided prospectively recorded data on their menstrual cycles for many years. Dr. Alan Treloar (University of Minnesota) originally recruited the women in the 1930s; the authors used data reported by these women from 1930 through 1977. They identified nuanced characteristics of menstrual histories that were strongly predictive of the onset of menopause, focusing on measures of central tendency (the mean), variability (standard deviation), and serial irregularity (approximate entropy), the last of which quantifies a continuum that ranges from totally ordered to completely random. They controlled for other characteristics known to affect age at menopause, including use of exogenous hormones, number of births, and extent of breastfeeding. Although cycle length and variability increased with the approach of menopause, the authors found that serial irregularity decreased and was a strong predictor of its onset. This finding constitutes an important piece of information not attainable with conventional statistical summaries of menstrual histories.

[Reference population values for the Spanish Child Health and Illness Profile-Adolescent Edition (CHIP-AE) using a representative school-based sample]

AIM

The Child Health and Illness Profile (CHIP-AE) is a generic health status instrument for adolescents aged 12-19 years adapted for use in Spain. The aim of this study was to obtain reference population values of the Spanish version of the CHIP-AE.

METHODS

The CHIP-AE was administered to a representative sample of adolescents from schools in Barcelona. The sample was selected by using cluster-sampling, stratified by type of school (public or private) and an ecological socioeconomic index (Indice de Capacidad Familiar: low, middle, and high). The CHIP-AE scores were standardized to a mean of 20 and a standard deviation (SD) of 5. Means and percentiles were computed. Means were compared by age, gender, and socioeconomic status using analysis of variance.

RESULTS

The response rate was 81% (n = 902). The distribution of the CHIP-AE scores presented a wide range with scores generally skewed toward positive health status. Nevertheless, the results suggest that the sample selected from a general population was not free of health problems. Twenty-five percent of adolescents presented scores below 17.2 in the domain of discomfort, indicating an effect size of 0.56 standardized SD units. The distribution of scores in the reference samples from Barcelona was similar to the original results in Baltimore (USA), with some marginal differences in individual risks.

CONCLUSIONS

The CHIP-AE systematically gathers information on health domains in adolescents. The results from this reference sample will allow comparisons with adolescents from other regions, and/or with different health problems, as well as description of inequalities in health during adolescence.

Characterisation of the expression of a novel constitutive maize promoter in transgenic wheat and maize

A novel constitutive promoter from the maize histone H2Bgene was recently identified. In this study, we characterised H2B promoter activity in both wheat and maize tissues using the gusA reporter gene and two synthetic versions of the pat (phosphinothricin acetyl transferase) selectable marker gene, namely mopat and popat. Analyses of transgenic plants showed that the H2B promoter is able to drive the expression of gusA to strong, constitutive levels in wheat and maize tissues. Using an H2B:mopat construct and phosphinothricin selection, we recovered transgenic wheat plants at efficiencies ranging from 0.3% to 7.4% (mean 1.6%), and the efficiency of selection ranged from 40% to 100% (mean 77.7%). In another application, H2B was combined with the maize Ubi-1 or the maize Adh-1 intron to drive the expression of mopat and popat. Transformation efficiencies with the Ubi-1 intron were between 1.4- to 16-fold greater than with the Adh-1 intron. However, the use of either of the introns was necessary for the recovery of transgenic plants. Mopat gave higher transformation efficiencies and induced higher levels of PAT protein in maize tissues than popat.

The North Lewisham telepsychiatry project: beyond the pilot phase

The integration of a telepsychiatry application into an inner-city community mental health service was evaluated over 10 months. ISDN videoconferencing at 128 kbit/s was employed for psychiatric consultation between a primary care centre and a community mental health centre. A convenience sample of patients and referrals seen by videoconferencing was compared with a sample seen face to face. During the study period 19 patients were managed by videoconferencing and 12 face to face. There were 162 consultations, comprising 81 prearranged teleconsultations and 81 prearranged face-to-face consultations. There was no significant difference in attendance between videoconferencing and face-to-face consultations. Nine of the videoconferencing new referrals had not completed their treatment at the end of the study period, compared with only three in the face-to-face group. This implies that it takes longer to complete treatment for new referrals managed by videoconferencing.

A systematic approach to erectile dysfunction in the cardiovascular patient: a Consensus Statement--update 2002

Sexual activity is no more stressful to the heart when compared with a number of other natural daily activities, e.g. walking one mile on the level in 20 minutes. The cardiac risk of sexual activity in patients diagnosed with cardiovascular disease is minimal in properly assessed and advised patients. Erectile dysfunction (ED) is extremely common, affecting over half of men aged 40-70 years, and increases in frequency with age. ED and cardiovascular disease share many of the same risk factors and commonly coexist. ED in the otherwise asymptomatic man may be a marker for underlying coronary artery disease. ED in the diagnosed cardiovascular patient should be identified by routine questioning in general practice. Modern therapies can restore a sexual relationship in the majority of patients with ED and can lead to a substantial improvement in quality of life. The majority of patients assessed to be at low or intermediate cardiac risk, as defined later in this paper, can be effectively managed in primary care. Primary care treatment for ED in patients defined as high risk can be initiated following a specialist opinion and/or confirmation that the patient's cardiovascular condition is stabilised. There is no evidence that currently licensed treatments for ED add to the overall cardiovascular risk in patients with or without diagnosed cardiovascular disease. If one form of therapy is not effective, follow-up will identify the need for alternative approaches. The pro-active management of ED in the cardiovascular patient provides an ideal and effective opportunity to address other cardiovascular risk factors and improve treatment outcomes.

Insertional tagging of regulatory sequences in tritordeum; a hexaploid cereal species

As an approach to isolate novel cereal promoters, promoterless uidA constructs and particle bombardment were used to transform tritordeum. Five of eight transgenic lines containing uidA sequences showed evidence of promoter tagging. Expression of uidA was detected in four lines as: constitutive expression, expression in short cells of the epidermis of the spikelets, expression in pollen grains and in cells of the epidermis of the spikelet, and expression in anther primordia and pollen grains. In the fifth line, the uidA was shown by RT-PCR to be transcribed, but no GUS activity was detected. The different patterns of uidA expression indicate that different regulatory sequences were tagged in each of these lines. Analysis of the progeny resulting from self-fertilisation of the primary tagged plants, indicate that the transgenes integrated at one or two loci and the patterns of expression were stably inherited. To our knowledge, this is the first report of promoter tagging in cereals by direct gene transfer.

Antidepressant medications: a review of the evidence for drug-induced sexual dysfunction

BACKGROUND

Sexual dysfunction is recognised as a potential side effect of antidepressant therapy. However, there is little detailed information on the prevalence of drug-induced sexual dysfunction or the differences, if any, between available drugs. This article is a critical review of the literature in the area.

METHODS

English-language studies on sexual dysfunction and depression or antidepressant treatments were identified by searching Medline and supplemented by manual review of their reference lists and recent journal issues available in a library. Trials of antidepressant use in anxiety disorders were identified from a Medline search and their adverse events tables scanned for data on sexual dysfunction. All trials were assessed according to predefined criteria.

RESULTS

Sexual dysfunction is widespread in the healthy non-depressed population and is a recognised symptom of depression and/or anxiety disorders. Sexual dysfunction has been reported with all classes of antidepressants (MAOIs, TCAs, SSRIs, SNRIs and newer antidepressants) in patients with depression and various anxiety disorders. Numerous studies have been published, but only one used a validated sexual function rating scale and most lacked either a baseline or a placebo control or both. None met all of the pre-defined assessment criteria.

LIMITATIONS

The search techniques may have missed some studies and publication bias cannot be ruled out.

CONCLUSIONS

The existing literature confirms sexual dysfunction as a possible adverse event of all antidepressants, but it is not sufficiently robust to support claims for differences in the incidence of drug-induced sexual dysfunctions between existing antidepressant therapies. Prescribing decisions should be based on a careful assessment of the benefits and risks of therapy in the individual patient.

The role of the partner in erectile dysfunction and its treatment

Advances in pharmacological, mechanical, and surgical treatment for erectile dysfunction (ED) now allow erectile function to be re-established in most men who experience this problem. However, re-establishing erectile function and re-establishing a satisfying sexual interaction with a partner are totally different objectives, and when the latter is not met, the man may re-present with treatment failure or withdraw from treatment altogether. All nontalking therapies focus on the penis as the dysfunctional element, and all too often clinicians fail to appreciate that ED can result from problems in the patient's partner and/or difficulties in their relationship. This article examines the role of the partner in the etiology, assessment, and treatment of ED.

The use of telepsychiatry in the brief counselling of non-psychotic patients from an inner-London general practice

Brief counselling of 13 non-psychotic patients was carried out using an interactive television link, in order to assess patient satisfaction with this technique. Informed consent was obtained from all patients before the videoconferencing sessions, which were conducted at 128 kbit/s. Over the four-month study period, 11 men and two women participated in a total of 29 sessions. A total of 28 questionnaires were completed. After the sessions, 93% of patients agreed that they would like to use this medium for communication again, 75% stated that they were able to see everything that they needed to see and 86% agreed that they were able to hear everything they needed to hear. Overall, these findings indicate that patients were happy with the standard of care they received.

Elementary school-aged children's reports of their health: a cognitive interviewing study

There are no standard methods for assessing the quality of young children's perceptions of their health and well-being and their ability to comprehend the tasks involved in reporting their health. This research involved three cross-sectional studies using cognitive interviews of 5-11-year-old children (N = 114) to determine their ability to respond to various presentations of pictorially illustrated questions about their health. The samples had a predominance of children in the 5-7-year-old range and families of lower and middle socio-economic status. The research questions in Study 1 involved children's ability to convert their health experiences into scaled responses and relate them to illustrated items (n = 35); Study 2 focused on the type of response format most effectively used by children (n = 19); and Study 3 involved testing children's understanding of health-related terms and use of a specific recall period (n = 60). The results of Study 1 showed that children identified with the cartoon drawing of a child depicted in the illustrated items, typically responding that the child was at or near their own age and of the same gender, with no differences related to race. Study 2 results indicated that children responded effectively to circles of graduated sizes to indicate their response and preferred them to same-size circles or a visual analogue scale. Tests of three-, four-, and five-point response formats demonstrated that children could use them all without confusion. In Study 3, expected age-related differences in understanding were obtained. In fact, the 5-year-old children were unable to understand a sufficient number of items to adequately describe their health. Virtually all children 8 years of age and older were able to fully understand the key terms and presentation of items, used the full five-point range of response options, and accurately used a 4-week recall period. Six- and seven-year-olds were more likely than older children to use only the extreme and middle responses on a five-point scale. No pattern of gender differences in understanding or in use of response options was found. We conclude that children as young as eight are able to report on all aspects of their health experiences and can use a five-point response format. Children aged 6-7 had difficulty with some health-related terms and tended to use extreme responses, but they understood the basic task requirements and were able to report on their health experiences. These results provide the guidance needed to develop and test a pediatric health status questionnaire for children 6-11 years old.

Epidemiological investigation of the central Scotland outbreak of Escherichia coli O157 infection, November to December 1996

On Friday, 22 November 1996, the microbiologist at a hospital in Lanarkshire, Scotland, identified presumptive Escherichia coli O157 in faecal specimens submitted by three patients with bloody diarrhoea, and confirmed its presence in one. Over the next 6 h, 12 more potential cases were identified. Investigations first indicated then confirmed a single food premises as the source of infection. Effective control measures were applied promptly. The outbreak was declared over on 20 January 1997, by which time 512 cases had been identified, and infection with the outbreak strain confirmed in 279. Twenty deaths occurred in cases during the outbreak and there were two more in cases during 1997. Seventeen of these deaths resulted from the outbreak. This paper describes the outbreak's epidemiological investigation, referring to other investigations, and control measures, where appropriate.

Procedures allowing the transformation of a range of European elite wheat (Triticum aestivum L.) varieties via particle bombardment

Ten current European wheat varieties were transformed at efficiencies ranging from 1-17% (mean 4% across varieties) following modifications in particle bombardment and tissue culture procedures. All plants surviving phosphinothricin selection were screened for uidA and bar gene activity, and for the presence of marker gene sequences by PCR analysis. A minimum of 35% plant 'escape' frequency was achieved with selection on 4 mg l(-1) gluphosinate ammonium after shoot initiation. Mean co-transformation frequency with various genes-of-interest was 66%. The estimated number of insertions of the uidA gene in 25 lines were; 1-2 in 32%, 3-5 in 52%, and 6-8 in 16% of lines. In T(1) progenies, marker genes segregated in a Mendelian fashion in 50% of 39 lines analysed, as determined by transgene activity assays. Based on PCR analysis, it appeared that in some lines the occurrence of distorted segregation was due to poor transmission of the transgenes.

The effects of regular source of care and health need on medical care use among rural adolescents

OBJECTIVE

To examine those factors associated with the use of different types of ambulatory health services in a rural adolescent population.

METHODS

The student bodies of 2 middle schools and 2 high schools in rural areas in a mid Atlantic state (N = 1615) were surveyed using a self-administered health status and health services use instrument. Logistic regression was used to assess factors predicting receipt of (1) preventive services, (2) problem-focused services, and (3) emergency services.

RESULTS

One third of the rural youth reported having received preventive services within the previous 3 months; 41% received problem-focused care, and 18% received emergency services. Having the same provider for both preventive and illness care was the most consistent and significant predictor of receipt for all types of ambulatory services. Of special note is the greater use of emergency services when subjects did not have a consistent provider for both preventive and illness care. Health need variables, measured across a wide range of domains, were additionally predictive, and their significance varied according to the type of services received.

CONCLUSIONS

This study provides compelling evidence that for rural adolescents, having a regular source of care and medical need are the most important predictors of use across a variety of types of ambulatory care.

Sequence and analysis of chromosome 5 of the plant Arabidopsis thaliana

The genome of the model plant Arabidopsis thaliana has been sequenced by an international collaboration, The Arabidopsis Genome Initiative. Here we report the complete sequence of chromosome 5. This chromosome is 26 megabases long; it is the second largest Arabidopsis chromosome and represents 21% of the sequenced regions of the genome. The sequence of chromosomes 2 and 4 have been reported previously and that of chromosomes 1 and 3, together with an analysis of the complete genome sequence, are reported in this issue. Analysis of the sequence of chromosome 5 yields further insights into centromere structure and the sequence determinants of heterochromatin condensation. The 5,874 genes encoded on chromosome 5 reveal several new functions in plants, and the patterns of gene organization provide insights into the mechanisms and extent of genome evolution in plants.

Controlled studies on women presenting with sexual drive disorder: I. Endocrine status

A single mid-cycle blood sample was obtained from 15 premenopausal female patients presenting with lifelong absence of sexual drive and from a control group of women with intact sexual drive. Serum levels of testosterone, 5-dihydrotestosterone (5-DHT), 17 beta oestradiol, sex hormone binding globulin, and prolactin were measured and indices of free testosterone and 5-DHT were derived. During the menstrual cycle in which the blood samples were obtained, the study subjects kept a diary of their sexual desire and activities. The only endocrine parameter that is significantly different between the two groups is free testosterone, which is lower in the patients than in the control women. Associations between endocrine parameters and indices of sexual behavior were examined. In the control group, average daily sexual thoughts correlates positively with total testosterone, free testosterone index, and free 5-DHT. Feeling of "need for sex" correlates positively with free 5-DHT index and free testosterone index. Experience of sexual thoughts correlates with need for sex, and average frequency of masturbation correlates negatively with age. In both groups, average coital frequency correlates with free testosterone index.