Person Focused Training: a model for delivering positive behavioural supports to people with challenging behaviours.

BACKGROUND: Person Focused Training is introduced as a model of service delivery for people with severe challenging behaviours. It is defined as training and supporting staff to conduct functional assessments and to design and implement positive behavioural support for specific individuals with challenging behaviours. METHOD: Longitudinal outcome data are presented from 138 behaviour support plans developed by staff over a seven year period were analysed to determine reductions in frequency of challenging behaviours. Degree of behaviour change was determined across topography of behaviour, gender, age, level of disability, location of residence and role of course participant. RESULTS: Results indicate that the implementation by staff of behaviour support plans are associated with significant improvement in 77% of cases at an average follow-up of 22 months after implementation of support plans. Only location of residence was identified as related to reduction in challenging behaviours with large residential centres being associated with lower rates of behavioural improvement. CONCLUSIONS: It is argued that Person Focused training may represent an alternative to existing models of supporting individuals with challenging behaviours. The implications of front-line staff designing and implementing behaviour support plans for the organisation of services and the role of the clinical psychologist are considered.

Efficacy of a chlorine dioxide-containing mouthrinse in oral malodor.

Studies have suggested that when chlorine dioxide is contained in a mouthrinse, it neutralizes volatile sulfur compounds in mouth air. The efficacy of a chlorine dioxide-containing mouthrinse in the reduction of oral malodor was evaluated in a randomized, controlled, double-blind, parallel group study of 31 men and women. Subjects with a maximum odor pleasantness score of < or = -1 (slightly unpleasant/stale) on a 7-point ordinal scale at both screening and baseline were randomized to treatment with the chlorine dioxide-containing rinse (n = 16) or distilled water (negative control) (n = 15). Oral malodor was evaluated at baseline (prerinse) and at 2, 4, 8, 24, 48, 72, and 96 hours postrinse by both a trained, previously calibrated panel of organoleptic judges and a factory-calibrated portable sulfide monitor. The sulfide monitor measured concentrations of volatile sulfur compounds in the subjects' mouth air 3 minutes after completion of the organoleptic assessment at each time point. The correlation between the organoleptic assessments and log-transformed sulfide monitor values was evaluated. With the chlorine dioxide mouthrinse, a statistically significant improvement in odor pleasantness, reduction in odor intensity, and reduction in oral volatile sulfur compound concentrations compared to the water control were evident at 2 hours postrinse and persisted through 8 hours postrinse. The mean (+/- SD) odor pleasantness improved from -1.25 +/- 0.31 at baseline to -0.73 +/- 0.33 at 2 hours postrinse in the chlorine dioxide group compared to -1.40 +/- 0.38 at baseline to -1.31 +/- 0.67 at 2 hours in the control group (P < 0.01). Odor pleasantness reached its maximum change from baseline to 0.63 +/- 0.45 at 8 hours postrinse. The mean (+/- SD) log-transformed sulfide monitor measurement decreased from 5.40 +/- 0.29 at baseline to 5.17 +/- 0.13 at 2 hours postrinse in the chlorine dioxide group, but increased from 5.47 +/- 0.40 at baseline to 5.56 +/- 0.54 at 2 hours in the control group (P < 0.01). As measured by the sulfide monitor, the mean volatile sulfur compound concentration in the chlorine dioxide group reached its minimum level at 8 hours postrinse (change from baseline in the log-transformed Halimeter measurement of -0.35 +/- 0.31). Thus, this study demonstrates that a one-time use of a chlorine dioxide-containing mouthrinse significantly improves mouth odor pleasantness, reduces mouth odor intensity, and reduces volatile sulfur compound concentrations in mouth air for at least 8 hours after use.

Types of planning: can artificial intelligence yield insights into prefrontal function?

In this paper, some of the features of models of planning emerging from the area of artificial intelligence (AI) are explored. The goal of this exposition is to explain how researchers are getting machines to attack problems that appear to be similar to those handled in the human prefrontal cortex. In particular, I tried to explain some of the features of AI models that might help explain how planned behavior can occur, with an eye toward examining the specific information-processing constraints necessary for computational models of planning. I described how some AI researchers are converging on a model in which (1) a memory of complex planning information is used in guiding long-term behavior, (2) hierarchically ordered schemata are used to represent this information, (3) activation spreading-like effects occur both in the choice of the memory schemata to use and in monitoring the processing during the execution of those schemata, (4) schemata processing is activated and/or affected by environmental stimuli, and (5) multiple schemata with differing temporal extent are active in parallel. A specific AI planning model, developed in conjunction with Dr. Lee Spector of Hampshire College, was also presented; it was shown how it uses the features above to give rise to interesting planning behaviors for robotic systems.

Intrinsic positive end-expiratory pressure in ambulatory patients with airways obstruction.

In patients with severe expiratory airflow limitation, dynamic hyperinflation often occurs when inspiratory efforts are initiated at a thoracic volume above the relaxation point of the respiratory system. The result is intrinsic positive end-expiratory alveolar pressure (PEEPi). To determine whether PEEPi occurs in ambulatory patients, we measured alveolar pressure (Palv) noninvasively during tidal breathing in 8 normal subjects, 15 asthmatic subjects, and 19 patients with COPD, using a body plethysmographic technique that includes computerized corrections for nonlinear pneumotachometer output and for plethysmograph leakage. In all 8 normal subjects, 9 asthmatic subjects, and 3 COPD patients, Palv descended smoothly to zero at end expiration. In contrast, among each of the remaining 22 patients, there was an abrupt change in slope of the Palv tracing near end expiration, identifying the onset of the next inspiratory effort and indicating the presence of PEEPi, ranging from 0.2 to 9.5 cm H2O. PEEPi was significantly correlated with FRC (% of predicted); PEEPi = (0.040 x %FRC) - 3.65, r = 0.73, p < 0.001, and with the reciprocal of FEV1 (% of predicted), PEEPi = (138/%FEV1) - 1.34, r = 0.69, p < 0.001. PEEPi could be elicited in normal subjects by severe expiratory resistive loading but not by the increased expiratory muscle activity occurring during an MVV maneuver. We conclude that PEEPi is common in patients with airways obstruction, even without overt ventilatory failure, and that its severity is generally in proportion to the severity of the hyperinflation and the airways obstruction.

An evaluation of the accuracy of Assess and MiniWright peak flowmeters.

With the advent of small inexpensive peak flowmeters, the at-home monitoring of peak flow rates has become an invaluable aid in the treatment of asthmatic patients. In this study, we evaluated the performance of the MiniWright and Assess peak flowmeters for accuracy and reproducibility. Measurements were made at varying peak flow rates and compared with those obtained simultaneously by a calibrated pneumotachograph. When this segment of the study was completed, the peak flow devices were subjected to 200 uses and were then retested. Four MiniWright peak flowmeters that had been extensively used in our clinic were tested as well. The Assess peak flowmeter was more accurate than the MiniWright at low flow rates (less than 300 L/min), while the MiniWright meter was more accurate at high flow rates (greater than 400 L/min). We also found that the accuracy of the MiniWright meter deteriorated after 200 uses and worsened further after extensive use, while the Assess meter retained its accuracy after 200 uses.

Maximal inspiratory pressure is not a reliable test of inspiratory muscle strength in mechanically ventilated patients.

Maximal Inspiratory pressure (MIP) is an important clinical method used to assess respiratory muscle strength. The reliability and reproducibility of this measurement in mechanically ventilated patients is not certain. In 14 stable, mechanically ventilated patients, capable of spontaneous inspiratory efforts, we assessed maximal inspiratory efforts using the technique originally described by Marini and associates. MIP was measured in triplicate, by one to five experienced investigators, on one to seven successive days, for a total of 396 determinations on 54 patient days. The coefficients of variation among the triplicate efforts averaged 12 +/- 1%, indicating the test to be highly reproducible. There was significant variation among the MIP reported by different investigators studying the same patient on the same day (32 +/- 4%). The differences between best MIP by different investigators averaged 12.6 +/- 1.3cm H2O (40 +/- 4%). In 17 of 44 cases, one investigator placed MIP above -30cm H2O, whereas another placed it below. ANOVA showed that MIP was significantly affected by investigator (p less than 0.0001) as well as by patient (p less than 0.0001). Because "true" MIP must be equal to or greater than the best measured MIP, these data indicate that the MIP is commonly underestimated in patients receiving mechanical ventilation, even when standardized technique is used. Furthermore, our data show that reproducibility of triplicate MIP determination by a single observer does not indicate that the test is reliable.

Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam.

The Observer's Assessment of Alertness/Sedation (OAA/S) Scale was developed to measure the level of alertness in subjects who are sedated. This scale was tested in 18 subjects in a three-period crossover study to assess its reliability and its criterion, behavioral, and construct validity. After receiving either placebo or a titrated dose of midazolam to produce light or heavy sedation, each subject was administered two sedation scales (OAA/S Scale and a Visual Analogue Scale) and two performances tests (Digit Symbol Substitution Test and Serial Sevens Subtraction). Two raters individually evaluated the subject's level of alertness on each of the two sedation scales. The results obtained on the OAA/S Scale were reliable and valid as measured by high correlations between the two raters and high correlations between the OAA/S Scale and two of the three standard tests used in this study. The OAA/S Scale was sensitive to the level of midazolam administered; all pairwise comparisons were significant (p less than 0.05) for all three treatment levels at both test periods.

A comparison of clinical and self-report diagnoses of DSM-III personality disorders in 552 patients.

This report examines the relationship between clinicians' diagnoses of personality disorder and self-report diagnoses of personality disorder obtained from the Personality Diagnostic Questionnaire (PDQ). The results from 552 patients showed general lack of agreement between clinical and self-report diagnoses of DSM-III personality diagnoses. The best agreement obtained was for Borderline Personality Disorder: k = 0.46, and r = .51 for scaled ratings. Possible sources of disagreement including failings of the self-report questionnaire, difficulties in relying upon patients' self-reports, lack of reliability of clinical diagnoses of personality, and possible inherent lack of reliability of several of the DSM-III personality disorders are discussed.

Flumazenil: US clinical pharmacology studies.

Flumazenil, a benzodiazepine antagonist, blocks the central effects of benzodiazepines by competitive interaction at the receptor site. Two double-blind, placebo-controlled, randomized studies in healthy volunteers (110/study) were performed to determine the minimal effective dose of flumazenil required to reverse the sedative, psychomotor and amnesic effects of benzodiazepines used to produce conscious sedation. Conscious sedation was produced by i.v. diazepam (12-30 mg) in one study and i.v. lorazepam (0.045 mg kg-1) in the other. Intravenous flumazenil (0.001, 0.003, 0.007 or 0.014 mg kg-1) or placebo was administered after diazepam or lorazepam. Assessment of sedation, psychomotor performance and recall/recognition were made both before and after the benzodiazepine as well as serially after flumazenil or placebo. Doses as low as 0.007 and 0.014 mg kg-1 flumazenil consistently reversed diazepam- and lorazepam-induced effects, respectively. The duration of reversal produced by varying doses of flumazenil (0.2, 0.6, 1.0 or 3 mg) was evaluated in 50 volunteers in a double-blind, placebo-controlled, parallel group study. A constant level of conscious sedation was produced by a continuous infusion of midazolam. Assessments of sedation and psychomotor performance were assessed both before and at varying times after the administration of flumazenil or placebo. Preliminary results indicate that the duration of reversal produced by 3.0 mg flumazenil was longer than that produced by any of the lower doses. While the mean duration of reversal produced by the lower doses was comparable, the 0.2 mg dose resulted in the greatest between subject variability and only partial rather than complete reversal. Two further double-blind, placebo-controlled studies were done in healthy volunteers (45/study) to evaluate the safety of flumazenil 1.0 mg or placebo given i.v. to reverse midazolam-induced sedation in subjects who had been treated for up to 14 days with either oral diazepam or triazolam. No clinically significant changes were noted in laboratory test values, electrocardiograms or vital signs monitored for up to 36 h after flumazenil or placebo in any pre-treatment group.