Primary pneumococcal peritonitis can be the first presentation of a familial complement factor I deficiency1

Primary pneumococcal peritonitis is a rare infection that has been described in women but has not been previously linked with immunodeficiency. The complement system plays a central role in immune defence against Streptococcus pneumoniae and, in order to evade complement attack, pneumococci have evolved a large number of mechanisms that limit complement‐mediated opsonization and subsequent phagocytosis. We investigated an apparently immunocompetent woman with primary pneumococcal peritonitis and identified a family with deficiency for complement factor I. Primary pneumococcal peritonitis should be considered a possible primary immunodeficiency presentation.

Combined exposures to workplace psychosocial stressors: relationships with mental health in a sample of NZ cleaners and clerical workers

BACKGROUND

A combined measure of two common psychosocial stressors, called job pressure has previously been shown to be strongly associated with poor mental health in high status workers. This study tests the generalizability of this association to lower status workers.

METHODS

A national random sample of cleaners and clerical workers was obtained from the New Zealand (NZ) electoral roll by occupational title (n = 596). Cross-sectional data on job stressors, demographics, and mental health (GHQ-12) was collected by computer-assisted telephone interviews.

RESULTS

Combined exposure to low job control, high job demands, and job insecurity (high job pressure) was associated with markedly elevated odds (13-fold or higher) of poor mental health after adjustment for age, sex, occupation, and education.

CONCLUSION

Combined with previous findings this suggests simultaneous exposure to more than one occupational psychosocial stressor may greatly increase the risk of poor mental health among both lower and higher status workers. This report adds to the larger literature in this area, supporting the need for expanded policy and practice intervention to reduce job stressors across the working population.

Multiple mechanisms are implicated in the generation of 5q35 microdeletions in Sotos syndrome

BACKGROUND

Sotos syndrome is characterised by learning difficulties, overgrowth, and a typical facial appearance. Microdeletions at 5q35.3, encompassing NSD1, are responsible for approximately 10% of non-Japanese cases of Sotos. In contrast, a recurrent approximately 2 Mb microdeletion has been reported as responsible for approximately 50% of Japanese cases of Sotos.

METHODS

We screened 471 cases for NSD1 mutations and deletions and identified 23 with 5q35 microdeletions. We investigated the deletion size, parent of origin, and mechanism of generation in these and a further 10 cases identified from published reports. We used "in silico" analyses to investigate whether repetitive elements that could generate microdeletions flank NSD1.

RESULTS

Three repetitive elements flanking NSD1, designated REPcen, REPmid, and REPtel, were identified. Up to 18 cases may have the same sized deletion, but at least eight unique deletion sizes were identified, ranging from 0.4 to 5 Mb. In most instances, the microdeletion arose through interchromosomal rearrangements of the paternally inherited chromosome.

CONCLUSIONS

Frequency, size, and mechanism of generation of 5q35 microdeletions differ between Japanese and non-Japanese cases of Sotos. Our microdeletions were identified from a large case series with a broad range of phenotypes, suggesting that sample selection variability is unlikely as a sole explanation for these differences and that variation in genomic architecture might be a contributory factor. Non-allelic homologous recombination between REPcen and REPtel may have generated up to 18 microdeletion cases in our series. However, at least 15 cannot be mediated by these repeats, including at least seven deletions of different sizes, implicating multiple mechanisms in the generation of 5q35 microdeletions.

MRI and neurological findings in macrocephaly-cutis marmorata telangiectatica congenita syndrome: report of ten cases and review of the literature

MRI and neurological findings in macrocephaly-cutis marmorata telangiectatica congenita syndrome: report of ten cases and review of the literature: We describe the clinical history and magnetic resonance imaging (MRI) findings in 10 children with the Macrocephaly-Cutis Marmorata Telangiectatica Congenita syndrome (M-CMTC--MIM 602501). This syndrome has recently been delineated within the general group of patients with Cutis Marmorata Telangiectatica (CMTC) as a distinct and easily recognisable entity. In contrast to most children with CMTC, patients with M-CMTC syndrome have a high risk of neurological abnormalities, such as hydrocephalus, megalencephaly, developmental delay and mental retardation. An MRI scan showed structural cerebral abnormalities in all of our patients, including megalencephaly, asymmetry of the cerebral hemispheres and abnormally increased signal of white matter. Seven patients also had Chiari type I malformation. Reviewing all reported cases, we propose appropriate surveillance for known complications.

Microarray based comparative genomic hybridisation (array-CGH) detects submicroscopic chromosomal deletions and duplications in patients with learning disability/mental retardation and dysmorphic features

The underlying causes of learning disability and dysmorphic features in many patients remain unidentified despite extensive investigation. Routine karyotype analysis is not sensitive enough to detect subtle chromosome rearrangements (less than 5 Mb). The presence of subtle DNA copy number changes was investigated by array-CGH in 50 patients with learning disability and dysmorphism, employing a DNA microarray constructed from large insert clones spaced at approximately 1 Mb intervals across the genome. Twelve copy number abnormalities were identified in 12 patients (24% of the total): seven deletions (six apparently de novo and one inherited from a phenotypically normal parent) and five duplications (one de novo and four inherited from phenotypically normal parents). Altered segments ranged in size from those involving a single clone to regions as large as 14 Mb. No recurrent deletion or duplication was identified within this cohort of patients. On the basis of these results, we anticipate that array-CGH will become a routine method of genome-wide screening for imbalanced rearrangements in children with learning disability.

Health of farmers in southland: an overview

AIM

To describe the health of farmers in Southland.

METHODS

Coss-sectional study of a random sample of farmers in Southland.

RESULTS

586 individuals were interviewed from 286 farms with a response rate of 65.4%. The prevalence of at least one injury in the last twelve months which prevented normal farm work was 17.1%. Low back pain was common with 54.6% reporting such an episode in the last twelve months. Noise-induced hearing loss was prevalent among men with 28.7% of those 45 years and over being affected. Levels of asthma appeared low with a point prevalence of 6.8%, with 4.6% on medication. There were 19.3% of male farmers who were obese. The prevalence of alcohol use disorder among men aged 15-24 years was 57.4%, and 39.0% among farm workers. Similarly, 32.0% of men in this age-group smoked, with 35.6% of farm workers being smokers.

CONCLUSIONS

Farmers experienced high levels of injury, low back pain and noise-induced hearing loss. Community intervention programmes to prevent injury remain a priority for farmers, although lifestyle factors should also be addressed, particularly among farm workers.

Sexual abuse in children and adolescents with intellectual disability

The present authors conducted a study of the occurrence of victimization and the perpetration of sexual abuse among 43 in-patients with intellectual disability aged between 9 and 21 years who were admitted to a child and adolescent psychiatric in-patient department over a period of 5 years. A retrospective case-note review was employed that explored the nature and severity of abuse in relation to the age, gender and level of disability. The prevalence of abuse or abusive behaviour, i.e. 14% of 300 admissions, did not change over time. In 13 out of the 43 cases, the issue of sexual abuse was identified after admission. Victimization alone occurred in 21 cases, perpetration alone in six cases, and both victimization and perpetration in 16 cases. Fifty per cent of the victims had been abused by a member of their close or extended family. Most cases (62%) were adolescents. There was only one instance of a victim being abused by a female. However, there were five girls who were perpetrators, all of whom had previously been victims. By contrast, 11 out of the 17 male perpetrators had been victims. Despite difficulties of disclosure, it was possible to establish that severely disabled patients had suffered sexual abuse. The present data support theories which (1) recognize gender differences in sexual abuse patterns and (2) have a developmental perspective, incorporating the influence of adolescence.

Psychopathology of sexual abuse in young people with intellectual disability

The present study addressed two issues using a sample of child and adolescent victims and perpetrators of sexual abuse: (1) the extent of post-traumatic stress disorder (PTSD) in the sample; and (2) the possible distinction between perpetrators whose motivations were sexually impulsive, and those who were controlling and abuse-reactive. Retrospective case material from 43 cases (21 victims only, and 22 perpetrators, of whom 16 were also victims) provided the data. Post-traumatic symptomatology was not common. Only one case of PTSD was found. Perpetrators could be distinguished by whether they had suffered sexual abuse alone, sexual and physical abuse, or neither. The proposed distinction between perpetrators received support. Sexual abuse directed at younger victims was associated with earlier experience of multiple forms of abuse. The present data does not support the view that post-traumatic symptoms following victimization are a mediator of sexual abuse perpetration. It is argued that an elaboration of the Williams & New developmental model of perpetration better fits the data.

Assessment of parents' concerns and evaluation of outcomes

BACKGROUND

Clinical and service evaluation often fails to accommodate sufficiently to parental perspectives and priorities concerning health interventions. Although parent satisfaction questionnaires are widely used, these assess issues chosen by the researcher. Quality of life research methods, however, can assess individual priorities.

METHODS

A Schedule for Evaluation of Quality of Life was adapted to record the nature, and relative importance of parental concerns about their child before child psychiatric hospital admission. Level of concern or worry was assessed pre- and post-admission, and at 1 year follow-up, with a waiting-list control. Data were analysed qualitatively and quantitatively for individuals and groups of cases.

RESULTS

The adapted instrument was feasible and clinically useful. It did not show repeated measurement effects but was sensitive to the effects of intervention (hospital admission). Effects (reduction in levels of concern) remained evident at 1 year follow-up.

CONCLUSION

The instrument is brief, non-intrusive, and sensitive to change. It has utility for clinical case evaluation. It may complement satisfaction questionnaires, and has advantages over rating scales for the evaluation of treatment outcomes.

A case of the new overgrowth syndrome--macrocephaly with cutis marmorata, haemangioma and syndactyly

Moore et al. [(1997) J Med Genet 70:67-73] and Clayton-Smith et al. [(1997) Clin Dysmorphol 6:291-302] have recently described a new overgrowth syndrome with macrocephaly, cutis marmorata, haemangiomas and digit syndactyly. Other features have included body asymmetry, hydrocephalus requiring shunting and developmental delay. All 22 cases reported are sporadic. We report a further case of this rare syndrome.

Molecular analysis of eight mutations in FBN1

Mutations in the gene encoding extracellular glycoprotein fibrillin-1 (FBN1) cause Marfan syndrome (MFS) and other related connective tissue disorders. In this study, eight mutations have been detected in MFS patients by heteroduplex analysis. These comprise two missense mutations, C1835Y and C2258Y in calcium-binding epidermal growth factor-like domains, two nonsense mutations, R1541X and R2394X in transforming growth factor beta1-binding protein-like domains, one splice site mutation, which has been detected previously, and three small insertions or deletions resulting in a frameshift. Fibroblast cells have been established from seven of the MFS patients and the biochemical effects of the mutations on fibrillin-1 synthesis and secretion assessed by pulse-chase analysis. Each cysteine mutation resulted in the delayed secretion of fibrillin-1 and both nonsense and frameshift mutations caused reduced levels of synthesis and/or deposition of fibrillin-1. Indirect immunofluorescence and rotary shadowing electron microscopy analysis of fibrillin microfibrils revealed no major differences between normal and patient samples. We discuss the relative merits of the biochemical techniques used in this study.

Client satisfaction with the New Zealand National Poisons Information Service

A telephone survey of a random sample of callers to the New Zealand National Poisons and Hazardous Chemicals Information Centre (NPC) was undertaken to assess public satisfaction with, and knowledge of, the NPC and to determine whether the NPC was meeting the needs of its users. The response from a sample of 433 individuals (354 members of the general public and 79 health professionals) was 79%. Maori and Pacific Island people were under--represented in the sample. Overall the level of satisfaction with the NPC was high with 91% of the respondents finding the information they received very useful. If the NPC had not been available, 81% of the public would have sought advice from a medical facility and 59% would have visited such a facility. It was estimated that the NPC could be saving the public health services in New Zealand (NZ) up to NZ $1.3 million annually. It was concluded that the NPC was meeting the needs of current users, although greater public awareness and improved access are needed particularly for Maori and Pacific Island people.

Chorion villus sampling and limb deficiency--cause or coincidence?

Chorion villus sampling (CVS) is a widely used technique in first trimester prenatal diagnosis. In the early 1990s, two clusters of babies with limb defects following CVS were reported, raising the possibility of a causal association between early CVS and transverse limb deficiency. The evidence for this association is reviewed and shows a diminishing risk for transverse limb deficiency with advancing gestation. The risk of limb deficiency extends through the period of limb morphogenesis and slightly beyond; falling from levels 10-20-fold above background at nine weeks and below, to levels approaching (or only a few-fold above) background at 11 weeks and beyond.

Needle stick injuries in country general practice

AIMS

The aims of this study were to determine the frequency of needle stick injury (NSI) in general practice, to determine what measures were being taken to protect against needle stick injury, and to gather other information regarding work practices, risk perception, and knowledge of transmission.

METHODS

A postal survey was undertaken of all general practitioners and one practice nurse per practice address in selected areas of New Zealand.

RESULTS

The response rate was 82%. An incidence rate of 22 needle stick injuries in 100 health care workers per 6 month period was found. For general practitioners alone the incidence rate was 25 in 100 per 6 month period and for practice nurses it was 17 in 100 per 6 month period. Recommended precautionary measures were not being followed by most individuals.

CONCLUSIONS

Needle stick injury is a substantial problem in general practice and exposes general practitioners and practice nurses to a serious risk of infection from bloodborne transmissible agents. All patients should be considered to pose a potentially high risk of infection and recommended precautionary measures should be followed at all times.

Differential allelic expression of a fibrillin gene (FBN1) in patients with Marfan syndrome

Marfan syndrome is a connective-tissue disorder affecting cardiovascular, skeletal, and ocular systems. The major Marfan locus has been identified as the FBN1 gene on chromosome 15; this codes for the extracellular-matrix protein fibrillin, a 350-kD constituent of the 8-10-nm elastin-associated microfibrils. We identified five MFS patients who were heterozygous for an RsaI restriction-site dimorphism in the 3' UTR of the FBN1 gene. This expressed variation was used to distinguish the mRNA output from each of the two FBN1 alleles in fibroblast cultures from these five patients. Three of the patients were shown to produce < 5% of the normal level of FBN1 transcripts from one of their alleles. This null-allele phenotype was not observed in 10 nonmarfanoid fibroblast cell lines.

Occupational injuries in Dunedin

Attendances for work-related injury at the accident and emergency department, Dunedin Hospital over a 10 week period are described. The number of workers attending from Dunedin city, St Kilda and Green Island boroughs was 655, the overall rate being 15.8/1000 workers. The injury rate varied according to age, sex, ethnicity, occupation and industry. Laceration, strain/sprain and foreign body in the eye were the most common injuries and machinery was the commonest cause of injury. Small factories had significantly higher rates for lost time injuries compared with large factories. Serious under reporting of occupational injury to the Department of Labour was identified.

A systematic comparison of feedback and staff discussion in changing the ward atmosphere

The efficacy of therapeutic programmes depends on several characteristics of the treatment environment. For this reason therapists are increasingly directing their efforts towards changing the social characteristics of treatment units. This study aimed to promote change in social climate by providing nursing staff with structured information about their unit. The 'real' and 'ideal' social climate of the unit was defined and assessed using the Ward Atmosphere Scale. All staff were asked to complete it during an assessment period. Feedback about their perception of the unit was provided to staff in two ways. One group of staff received written feedback only; a second group received in addition the opportunity to discuss the feedback and strategies for reducing the real-ideal discrepancies in four once-monthly meetings. The effect of the feedback on the social climate of the unit was ascertained by further assessment using the WAS and from interviews with all staff. The evaluation suggested that the feedback had contributed to changes in several procedures in the unit and to a reduction in the real-ideal discrepancies for the systems maintenance elements. The effect was greater for the group of staff who had the opportunity to discuss the feedback in a formal setting.

A move from hospital to community: evaluation of community contacts

A small-scale evaluation was made of the activities and social contacts of a group of young mentally handicapped people in one project, leaving hospital to a house in the community. The results are consistent with other recent work in suggesting that residential provision in small homes for people with severe or profound intellectual or multiple handicaps is likely to lead to increased family contact, increased participation in activities outside of the residence, and an increased frequency and duration of contact with non-handicapped people. The study suggests that many of these benefits of life in the community are dependent in various ways upon the staff employed. The nature of the young people's social contacts is examined and conclusions are drawn about specific issues, including staff selection and training, and attention to the maintenance as well as the provision of social contact.

Professional depression, 'burnout' and personality in longstay nursing

Conceptualizations of 'burnout' vary between authors. Some descriptions of burnout show strong similarities to depression in the work setting, or 'professional depression' as described by Oswin [Children Living in Long Stay Hospitals, 1978. Heinemann, London]. This study supported such a similarity, and demonstrated a considerable extent of depressed mood amongst nursing staff in longstay settings, which was particularly significant amongst male staff. A number of distinct 'burnout' responses were evident amongst staff including not only 'professional depression' and depersonalization but also the avoidance of problems and decisions. Ambiguity about supervisors' expectations and success in meeting such expectations were associated with increased scores on each of these variables. Personality appeared to be related to staff's responses. Staff prone to direct hostility inwards on themselves were more likely to show an avoidance of problems and decisions. Those staff prone to direct hostility outwards were more likely to report an awareness of depersonalization toward others. Both these processes may in different ways affect patient care and relationships with other professionals.

Burnout and professional depression: related concepts?

In 1978 Oswin documented a process of 'professional depression' affecting some nursing staff in long-stay hospitals. This study tested the hypothesis that 'professional depression' in long-stay nursing and 'emotional exhaustion' as a component of burnout describe a similar phenomenon. This hypothesis was supported. The results are consistent with Cherniss' characterization of burnout, which appears to show considerable similarities to the concept of depression. In this study professional depression demonstrated a substantial correlation with depressed mood. Personality demonstrated significant relationships with burnout variables, extrapunitive hostility correlating with hardening toward others, intropunitiveness with avoidance as a coping response. These findings, although confined to hospital nurses, support the usefulness of approaches stressing the interaction between the work environment and the individual.

Interpersonal support amongst nurses at work

The needs for support of staff in human services work are often stated, but less often is the nature of such support clearly specified. This study attempts to clarify the nature of effective support from a superior, as perceived by qualified nursing staff working in psychiatric, mental handicap and medical settings. 'Personal respect', 'empathic attention' and 'absence of interpersonal defensiveness' appeared to be important components to such support. Staff on the same ward showed a high degree of agreement in judgements of their superior's personal respect and empathic attention, but perceived interpersonal defensiveness appeared more specific to perceptions or interactions between particular staff. Greater degrees of 'personal respect' experienced by staff were associated with reduced role ambiguity and reduced emotional exhaustion ('burnout'). The empathic attention reported as given by ward charge nurses was highly correlated with the personal respect they reported receiving from their own superior. These results support approaches which see respect, empathy and genuineness as important ingredients in helping relationships.

Maslach Burnout Inventory: factor structure and norms for British nursing staff

This study reports evidence that the factor structure of the Maslach Burnout Inventory scales may change when the scales are used as part of a wider range of items assessing feelings about work. Results from a sample of nursing staff suggested that feelings of being ‘emotionally drained’ were distinct from feelings of ‘frustration and discouragement about work.’ The extent (or lack) of personal accomplishment was confirmed as a salient factor among feelings about work. Scores on the scale for this sample of nurses were comparable with those in other studies, except that depersonalization scores were lower. This may reflect either lower incidence or lowered awareness.

The effectiveness of parent workshops in mental handicap service

Workshops designed to help parents teach their mentally handicapped children new skills and new habits were offered for 4 years as part of a wider service. This was the first time such a service had been available to any family within an area, population 250 000, and all families with mentally handicapped children under age 8 were invited to join the workshops. Workshops objectives were to teach parents skills in observation, selection and teaching of new skills and new behaviour, and to provide parents with confidence and support from other parents as well as professionals. workshops ran one evening/week for between 8 and 12 weeks, and nine workshops were held with a total of 40 families attending. Attendance was high and success was considerable with the problems tackled during the workshops. Nevertheless, the original objectives of the workshops were only fulfilled in part, as it is uncertain how much the methods taught during the workshop were applied to subsequent problems. The paper discusses the value of such workshops as a way of providing both practical help and support to families.

Sleeping pills and dream content

Almost all sleep-promoting drugs distort the natural pattern of sleep by suppressing rapid eye movement (REM) sleep, and cause a rebound to above-normal values on withdrawal which typically lasts about six weeks (Oswald, 1968, 1969). Furthermore, barbiturates reduce the number of eye movements per unit time in REM sleep (Oswald et al., 1963; Baekeland, 1967; Lester et al., 1968; Feinberg et al., 1969), with a rebound in eye movement (EM) profusion on withdrawal (Oswald, 1970). Non-barbiturate hypnotics do likewise, also with a rebound in EM profusion on withdrawal (Allen et al., 1968; Lewis, 1968).

The effect of acute administration of (meta trifluoro methyl-phenyl)-1-(benzoyl oxy) ethyl amino-2-propane (780 SE) and fenfluramine on human sleep

In contrast to other amphetamine derivatives, fenfluramine (40 mg) and 780 SE (300 mg) had no effect on the rapid eye movement (REM) phase of sleep. Like other amphetamines they disturbed sleep, increasing the number of shifts to stage 1 (drowsiness) and stage W (arousal).