Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems

Objectives: To analyze the attitude of physicians towards alerting in CPOE systems in different hospitals in different countries, addressing various organizational and technical settings and the view of physicians not currently using a CPOE.

Methods: A cross-sectional quantitative and qualitative questionnaire survey. We invited 2,600 physicians in eleven hospitals from nine countries to participate. Eight of the hospitals had different CPOE systems in use, and three of the participating hospitals were not using a CPOE system.

Results: 1,018 physicians participated. The general attitude of the physicians towards CPOE alerting is positive and is found to be mostly independent of the country, the specific organizational settings in the hospitals and their personal experience with CPOE systems. Both quantitative and qualitative results show that the majority of the physicians, both CPOE-users and non-users, appreciate the benefits of alerting in CPOE systems on medication safety. However, alerting should be better adapted to the clinical context and make use of more sophisticated ways to present alert information. The vast majority of physicians agree that additional information regarding interactions is useful on demand. Around half of the respondents see possible alert overload as a major problem; in this regard, physicians in hospitals with sophisticated alerting strategies show partly better attitude scores.

Conclusions: Our results indicate that the way alerting information is presented to the physicians may play a role in their general attitude towards alerting, and that hospitals with a sophisticated alerting strategy with less interruptive alerts tend towards more positive attitudes. This aspect needs to be further investigated in future studies.

The relationship between treatment attendance, adherence, and outcome in a caregiver-mediated intervention for low-resourced families of young children with autism spectrum disorder

Rates of participation in intervention research have not been extensively studied within autism spectrum disorder. Such research is important given the benefit of early intervention on long-term prognosis for children with autism spectrum disorder. The goals of this study were to examine how family demographic factors predicted treatment attendance and adherence in a caregiver-mediated randomized controlled trial targeting core deficits of autism spectrum disorder, and whether treatment attendance and adherence predicted outcome. In all, 147 caregiver-child dyads from a low-resourced population were randomized to in-home caregiver-mediated module or group-based caregiver education module treatment. Treatment attendance, adherence, and outcome (time spent in joint engagement) were the primary outcome variables. The majority of families who entered treatment (N = 87) maintained good attendance. Attendance was significantly predicted by socioeconomic status, site, and treatment condition. Families in caregiver-mediated module reported lower levels of treatment adherence, which was significantly predicted by site, condition, caregiver stress, and child nonverbal intelligence quotient. Dyads in caregiver-mediated module had significantly longer interactions of joint engagement, which was significantly predicted by an interaction between treatment attendance and condition. Overall, the results from this study stress the importance of considering demographic variables in research design when considering barriers to treatment attendance and adherence.

Does gender influence core deficits in ASD? An investigation into social-communication and play of girls and boys with ASD

Due to the predominance of boys diagnosed with autism spectrum disorders (ASD), girls are rarely studied independently. Research specifically focusing on play and social-communication in girls with ASD is extremely varied. We were interested in whether girls with ASD demonstrated equivalent social-communication and play skills in early childhood relative to boys, using two measures focused on the specific quantification of these variables. We also examined whether the associations between developmental variables and social-communication and play differed by gender. Forty girls with ASD were individually matched to 40 boys based on ASD severity. Our results suggest that girls and boys were more similar than different, however they also raise questions about the potential differential associations between development and requesting ability in girls and boys with ASD.

A comparative analysis of adult siblings' perceptions toward caregiving

Siblings of individuals with intellectual and developmental disabilities (IDD) are likely to become caregivers for their brothers and sisters. The expectations of and experiences with caregiving, however, may be different. In this study, using focus groups, we compared the perspectives of siblings who were current caregivers (n  =  25) to siblings who anticipated being caregivers (n  =  17). Responses were compared and contrasted across four areas: caregiving responsibilities, rewards, challenges, and opinions toward being paid as a caregiver. Both caregiver groups were knowledgeable about and invested in their brothers and sisters. Also, they both reported that they enjoyed bonding with their brothers and sisters. Challenges, for current caregivers, related to understanding and navigating the service system. In contrast, anticipated caregivers were concerned about planning for the future. Mixed viewpoints were expressed about receiving pay for providing care although a greater number of current caregivers were receptive to it as a means to supporting their own families.

Caregiver-mediated intervention for low-resourced preschoolers with autism: an RCT

OBJECTIVES

To compare 2 short-term, community caregiver training interventions for preschool-aged children with Autism Spectrum Disorder who had low resources. Low resource was defined by the US Department of Housing and Urban Development low-income index or 1 "indicator," (e.g., Medicaid eligibility). Child outcomes focused on joint engagement, joint attention, and play.

METHODS

Participants included 112 families of a child who had Autism Spectrum Disorder who met criteria for being low-resourced and who were randomly assigned to 1 of 2 3-month interventions, group caregiver education or individualized caregiver-mediated intervention (CMM). Children were assessed for social communication skills pre- and post-treatment, and followed up at 3 months.

RESULTS

All children improved in joint engagement and initiating joint attention, with significantly greater improvement by the CMM group. Outcomes on play skills were mixed, with improvement of symbolic play for the CMM group and no change in functional play skills. Joint engagement maintained over time for the CMM group, and initiating joint attention maintained for both groups over time.

CONCLUSIONS

This study is among the first randomized trials comparing 2 active interventions with a large sample of low-resourced families. Results suggest improvements in core autism deficits of joint engagement, joint attention, and symbolic play with relatively brief, caregiver-mediated interventions, but additional support is necessary to maintain and generalize these gains over time.

Brief report: longitudinal improvements in the quality of joint attention in preschool children with autism

Children with autism exhibit deficits in their quantity and quality of joint attention. Early autism intervention studies rarely document improvement in joint attention quality. The purpose of this study was to determine whether there was a change in joint attention quality for preschoolers with autism who were randomized to a joint attention intervention, symbolic play intervention, or a control group. Quality was defined as shared positive affect during joint attention as well as shared positive affect and utterances during joint attention. Interactions of group and time were found for both types of joint attention quality. During the follow up visits, the joint attention and symbolic play intervention groups produced more of these two types of joint attention quality than the control group.

Psychometric properties of the BASIS-24© (Behaviour and Symptom Identification Scale-Revised) Mental Health Outcome Measure

Objective. Outcome measurement in mental health services is an area of considerable clinical interest and policy priority. This study sought to assess the Behaviour and Symptom Identification Scale-24 (BASIS-24©), a brief, patient self-reported measure of psychopathology and functioning, in a UK sample, including establishing population norms for comparative purposes. Methods. Participants were 588 adults recruited from psychiatric inpatient, outpatient and primary care settings; and 630 adults randomly sampled from primary care lists who completed the BASIS-24©, and the Brief Symptom Inventory (BSI) at two time points. Results. BASIS-24© demonstrated adequate reliability (coefficient α values for combined clinical sample across subscales ranged from 0.75 to 0.91), validity and responsiveness to change (effect size for change of the BASIS-24© was 0.56 compared with 0.48 for BSI Global Severity Index). Population norms were established for the general population and adult in-patients (at in-take). The scale proved straightforward to complete across clinical settings. Variable rates of questionnaire distribution across clinical settings highlighted the ongoing challenge of incorporating outcome measures in clinical settings. Conclusion. BASIS-24© is a brief, easily administered, self-complete measure of mental well-being and functioning that adequately meets the requirements of reliability, validity and responsiveness to change required of an outcome measure.

NIM1 overexpression in Arabidopsis potentiates plant disease resistance and results in enhanced effectiveness of fungicides

The NIM1 (for noninducible immunity, also known as NPR1) gene is required for the biological and chemical activation of systemic acquired resistance (SAR) in Arabidopsis. Overexpression of NIM1 in wild-type plants (hereafter referred to as NIM1 plants or lines) results in varying degrees of resistance to different pathogens. Experiments were performed to address the basis of the enhanced disease resistance responses seen in the NIM1 plants. The increased resistance observed in the NIM1 lines correlated with increased NIM1 protein levels and rapid induction of PR1 gene expression, a marker for SAR induction in Arabidopsis, following pathogen inoculation. Levels of salicylic acid (SA), an endogenous signaling molecule required for SAR induction, were not significantly increased compared with wild-type plants. SA was required for the enhanced resistance in NIM1 plants, however, suggesting that the effect of NIM1 overexpression is that plants are more responsive to SA or a SA-dependent signal. This hypothesis is supported by the heightened responsiveness that NIM1 lines exhibited to the SAR-inducing compound benzo(1,2,3)-thiadiazole-7-car-bothioic acid S-methyl ester. Furthermore, the increased efficacy of three fungicides was observed in the NIM1 plants, suggesting that a combination of transgenic and chemical approaches may lead to effective and durable disease-control strategies.

Comparison of questionnaire, breath carbon monoxide and urine cotinine in assessing the smoking habits of Type 2 diabetic patients

AIMS

Previous studies have suggested that the self-reporting of smoking amongst diabetic patients is unreliable, and that objective markers such as breath carbon monoxide (CO) or urinary cotinine are needed. As these studies have been mostly in young Type 1 diabetic patients, the reliability of smoking history has been assessed in a large group of older Type 2 diabetic patients.

METHODS

Two hundred and ninety-nine Type 2 diabetic patients were investigated for smoking habits by unstructured questionnaire, breath CO, and urinary ratio.

RESULTS

Mean age of the group was 63 (range 30-80) years and 41% were female. Direct questioning suggested 77 (26%) to be smokers, and of these 852 had raised (>1 microg/mg) urinary cotinine-creatinine , and 71% raised (>8 p.p.m.) breath CO. Assuming urinary cotinine-creatinine as the 'gold standard', the sensitivity, specificity and positive predictive values for questionnaire were 97%, 95% and 85%, respectively; and for breath CO they were 74%, 98%, and 93%.

CONCLUSION

It is concluded that at least in this population of Type 2 diabetic patients, a structured smoking history appeared to identify current smokers with good accuracy.

Induced plant defence responses: scientific and commercial development possibilities

Recent work has demonstrated that plants have endogenous defence mechanisms that can be induced as a response to attack by insects and pathogens. There are two well-studied examples of these induced defence responses. Systemic acquired resistance (SAR) results in increased resistance to a broad spectrum of pathogens throughout a plant in response to localized necrosis caused by pathogen infection. The second example is the systemic induction of proteinase inhibitors to deter feeding by herbivores following an initial event of feeding. In addition, there is now preliminary evidence for other induced defence response pathways. By understanding the breadth of induced defence responses and the mechanisms used to control these pathways, novel plant protection strategies may be developed for use in agronomic settings. Rather than reducing crop losses caused by pests or pathogens by using chemicals that are designed to kill the offending organism, the plant's own defence mechanisms can be used to limit damage due to pests. Novel crop protection strategies based on genetic or chemical regulation of these induced responses show great potential. The first example of a crop protection product that acts by inducing an endogenous defence response pathway is now on the market. Bion reduces the level of pathogen infection in plants by activating SAR.

Seasonal affective disorder among primary care attenders and a community sample in Aberdeen

BACKGROUND

There are no large published studies of the prevalence of seasonal affective disorder (SAD) among UK populations.

AIM

To determine the prevalence of SAD among patients attending a general practitioner (GP).

METHOD

Patients aged 16-64 consulting their GPs in Aberdeen during January were screened with the Seasonal Pattern Assessment Questionnaire (SPAQ). SPAQs were also mailed to 600 matched patients, who had not consulted their GP during January. Surgery attenders who fulfilled SPAQ criteria for SAD were invited for interview to determine whether they met criteria for SAD in DSM-IV and the Structured Interview Guide for the Hamilton Rating Scale for Depression--Seasonal Affective Disorder Version (SIGH-SAD).

RESULTS

Of 6161 surgery attenders, 4557 (74%) completed a SPAQ; 442 (9.7%) were SPAQ cases of SAD. Rate of caseness on the SPAQ did not differ between surgery attenders and non-attenders. Of 223 interviewed SPAQ cases of SAD, 91 (41%) also fulfilled DSM-IV and SIGH-SAD criteria.

CONCLUSIONS

There is a high prevalence of SAD among patients attending their GPs in January in Aberdeen; this is likely to reflect a similar rate in the community.

Dedicated psychiatric care within general practice: health outcome and service providers' views

Health service reforms have led to relocation of care of the chronic mentally ill from institutions to the community, with subsequent demands on the primary health care team. Few studies have attempted to identify satisfactory models of care for this patient group. This study explores the impact of the employment of a community psychiatric nurse (CPN) by a general practice in Aberdeen city to co-ordinate care of discharged long-stay psychiatric patients resettled in hostels. A similar general practice with a comparable group of registered patients was selected as a control group. Patient health outcome was measured using the Health of the Nation Outcome Scales (HoNOS) and service providers' views on dedicated psychiatric care within general practice were explored using qualitative methods. Improvements in communication, liaison and drug management were reported in the intervention practice. A primary care-based CPN service dedicated to the care of the chronic mentally ill promoted a smooth transfer of care from long-term institutionalized care to the community setting.

Workload implications of community psychiatric nurse employment by a general practice: a pilot study

This study examines the impact of the employment of a community psychiatric nurse (CPN), dedicated to the care of patients with chronic mental illness, on general practice workload. Although the consultation rate with general practitioners for mental health reasons was significantly lower after CPN intervention, no differences were found in the total consultation rate.

The Arabidopsis NIM1 protein shows homology to the mammalian transcription factor inhibitor I kappa B

The NIM1 (for noninducible immunity) gene product is involved in the signal transduction cascade leading to both systemic acquired resistance (SAR) and gene-for-gene disease resistance in Arabidopsis. We have isolated and characterized five new alleles of nim1 that show a range of phenotypes from weakly impaired in chemically induced pathogenesis-related protein-1 gene expression and fungal resistance to very strongly blocked. We have isolated the NIM1 gene by using a map-based cloning procedure. Interestingly, the NIM1 protein shows sequence homology to the mammalian signal transduction factor I kappa B subclass alpha. NF-kappa B/I kappa B signaling pathways are implicated in disease resistance responses in a range of organisms from Drosophila to mammals, suggesting that the SAR signaling pathway in plants is representative of an ancient and ubiquitous defense mechanism in higher organisms.

The Arabidopsis NIM1 protein shows homology to the mammalian transcription factor inhibitor I kappa B

The NIM1 (for noninducible immunity) gene product is involved in the signal transduction cascade leading to both systemic acquired resistance (SAR) and gene-for-gene disease resistance in Arabidopsis. We have isolated and characterized five new alleles of nim1 that show a range of phenotypes from weakly impaired in chemically induced pathogenesis-related protein-1 gene expression and fungal resistance to very strongly blocked. We have isolated the NIM1 gene by using a map-based cloning procedure. Interestingly, the NIM1 protein shows sequence homology to the mammalian signal transduction factor I kappa B subclass alpha. NF-kappa B/I kappa B signaling pathways are implicated in disease resistance responses in a range of organisms from Drosophila to mammals, suggesting that the SAR signaling pathway in plants is representative of an ancient and ubiquitous defense mechanism in higher organisms.

Suppression and Restoration of Lesion Formation in Arabidopsis lsd Mutants

Systemic acquired resistance (SAR) is a broad-spectrum, systemic defense response that is activated in many plant species after pathogen infection. We have previously described Arabidopsis mutants that constitutively express SAR and concomitantly develop lesions simulating disease (lsd). Here, we describe two new mutants, lsd6 and lsd7, that develop spontaneous necrotic lesions and possess elevated levels of salicylic acid (SA) as well as heightened disease resistance, similar to the previously characterized lsd and accelerated cell death (acd2) mutants. Genetic analysis of lsd6 and lsd7 showed that the mutant phenotypes segregated as simple dominant traits. When crossed with transgenic Arabidopsis plants containing the SA-degrading enzyme salicylate hydroxylase, the F1 progeny showed suppression of both SAR gene expression and resistance. In addition, salicylate hydroxylase suppressed lesion formation in the F1 progeny, suggesting that SA or some SA-dependent process may have a role in pathogen-associated cell death. Surprisingly, lesions were restored in the lsd6 F1 progeny after the application of either 2,6-dichloroisonicotinic acid or SA. Lesions were not restored by treatment with either compound in the lsd7 F1 plants. Our findings demonstrate that steps early in the signal transduction pathway leading to SAR and disease resistance are potentiated by later events, suggesting feedback control of lesion formation.

Systemic acquired resistance in Arabidopsis requires salicylic acid but not ethylene

Systemic acquired resistance (SAR) is an inducible plant response to infection by a necrotizing pathogen. In the induced plant, SAR provides broad-spectrum protection against not only the inducing pathogen, but also against other, unrelated pathogens. Both salicylic acid (SA) and SAR-gene expression have been implicated as playing important roles in the initiation and maintenance of SAR. Here, we describe the characterization of transgenic Arabidopsis plants that express the bacterial nahG gene encoding salicylate hydroxylase, an enzyme that can metabolize SA. Strong, constitutive expression of this gene prevents pathogen-induced accumulation of SA and the activation of SAR by exogenous SA. We show that SAR in Arabidopsis can be induced by inoculation with Pseudomonas syringe pv. tomato against infection by a challenge inoculation with Peronospora parasitica. This response is abolished in transgenic, nahG-expressing Arabidopsis, but not in ethylene-insensitive mutants. These experiments support the critical role of SA in SAR and show that ethylene sensitivity is not required for SAR induction. The NahG Arabidopsis plants will be important for future studies aimed at understanding the role of SA in plant disease resistance mechanisms.

Free radical activity in young adult cigarette smokers

Cigarette smoke is capable of generating free radicals. In this study markers of free radical activity (thiobarbituric acid reactivity, superoxide dismutase and glutathione peroxidase) were measured in young adult smoking and non-smoking volunteers. No significant differences were found in any of the free radical markers between the two groups. The number of leucocytes was elevated and a positive correlation was found between the number of leucocytes and thiobarbituric acid reactivity in the smokers. The results from this study suggest that any free radical activity generated from long term cigarette smoking in young adults is adequately scavenged.

Cigarette smoking and free radical activity in young adults with insulin-dependent diabetes

Cigarette smoke is potentially capable of generating a high free radical load in the body and many patients with diabetes are smokers. This study was designed to investigate the relationship between long-term smoking and free radical activity in young adult insulin-dependent diabetic patients with no evidence of macrovascular disease. Eight-five patients (48 male) aged 17-40 years were studied. Mean duration of diabetes was 10.5 years (0.08-33) and 39 were cigarette smokers. All had normal serum creatinine levels. The free radical markers measured were: thiobarbituric acid reactive substances, glutathione peroxidase, and superoxide dismutase. No significant differences in thiobarbituric acid reactive substances, glutathione peroxidase, or superoxide dismutase, were found between the diabetic smokers and non-smokers. Also no difference was found comparing the diabetic patients with 40 non-diabetic control subjects (20 smokers). Persistent albuminuria was present in 16 patients (10 microalbuminuria) and free radical marker concentrations in these subjects were similar to the normoalbuminuric patients. This data suggests that any increase in free radical activity due to cigarette smoke is adequately scavenged in young adults with diabetes who are free of significant macrovascular disease.

Regulation of a hevein-like gene in Arabidopsis

An Arabidopisis cDNA clone was isolated that encodes a protein similar to the antifungal chitin-binding protein hevein from rubber tree latex. This hevein-like (HEL) mRNA was inducible by either turnip crinkle virus infection or ethylene treatment. In addition, expression was moderately inducible by treatment with the resistance-inducing compounds salicylic acid and 2,6-dichlorisonicotinic acid. The 786-bp cDNA contains an open reading frame of 212 codons. The deduced amino acid sequence contains a putative signal sequence of 21 amino acids followed by a 43-amino-acid cysteine-rich lectin domain and a 129-amino-acid carboxy-terminal domain. The predicted protein is approximately 70% identical to hevein, to the wound-inducible WIN1 and WIN2 proteins from potato, and to PR-4, a pathogenesis-related protein from tobacco.

Smoking in diabetic teenagers

The prevalence of smoking amongst a group of 77 diabetic teenagers aged 11-18 years attending two paediatric clinics was determined using a questionnaire and urine cotinine assay. Five individuals were identified as definite smokers with two further individuals being probable smokers, all of whom were aged 15 years or more. This low prevalence (9%) is in contrast to a 48% prevalence in a young adult diabetic clinic. Many diabetic teenagers appear to acquire a regular smoking habit after leaving the paediatric clinic so it is important that health education is targeted at this group.

Influence of exposure to tobacco smoke on serum alpha fetoprotein levels of women in midtrimester pregnancy

The influence of exposure to tobacco smoke on maternal serum alpha-fetoprotein (AFP) levels at 16 wk gestation was examined. Urinary cotinine levels were used to quantify exposure to tobacco smoke. Significantly higher levels of maternal serum AFP were found in 101 women who had more than 1.0 microgram cotinine/mg urinary creatinine compared with 180 women whose urinary cotinine levels were below this level [(mean +/- SD) 1.23 +/- 0.64 and 1.06 +/- 0.54 respectively; 95 per cent CI of difference of means 0.01-0.31; P < 0.05]. There was a mild albeit statistically significant correlation between urinary cotinine levels and maternal serum AFB (r 0.099; P < 0.05). However, the difference in maternal serum AFP levels between the two groups was not found to be significant, when adjustments for maternal body mass index were made.

Acidic and basic class III chitinase mRNA accumulation in response to TMV infection of tobacco

Complementary DNA clones encoding acidic and basic isoforms of the class III chitinase were isolated from Nicotiana tabacum. The clones share ca. 65% identity, are equally homologous to the class III chitinases from cucumber and Arabidopsis, and are members of small gene families in tobacco. An acidic class III chitinase was purified from the intercellular fluid of tobacco leaves infected with tobacco mosaic virus (TMV). Partial amino acid sequencing of the protein confirmed that it was encoded by one of the cDNA clones. The mRNAs of the class III chitinases are coordinately expressed in response to TMV infection, both in infected and uninfected tissue. The acidic and basic class III chitinases constitute previously undescribed pathogenesis-related proteins in tobacco.

Maternal smoking, urinary cotinine levels and birth-weight

The smoking habits of 300 consecutive pregnant women and of other members of their household were obtained by interview at 16 and 32 weeks' gestation and after delivery. Urine samples for estimation of cotinine were collected at the same times during pregnancy and on admission in labour. Both self-reports of active maternal smoking and urinary cotinine levels were significantly associated with lighter babies but urinary cotinine correlated the better. Active maternal smoking was associated with a decrease in birth-weight of 12 g for every cigarette smoked in a day while there was a decrease of 25 g in birth-weight for every microgram of cotinine/mg of urinary creatinine. Passive maternal smoking was associated with a decrease of 66 g in mean birth-weight but this decrease was not statistically significant. Self-reports of active and passive smoking accounted for 43% of the variation in urinary cotinine levels suggesting that urinary cotinine assays can be used to assess and monitor exposure to tobacco smoke in pregnancy.

Distribution of gold in blood during chrysotherapy

Measurements have been made using electrophoresis and neutron activation analysis of the distribution of gold in the blood of four patients who have responded well to chrysotherapy for rheumatoid arthritis. It has been shown that in these patients there is litte, if any, binding to the fibrinogen. The majority of protein-bound gold is associated with the albumin but significant amounts are bound to the other proteins. There is a small amount of gold associated with the blood cells.