Characterising repetitive behaviours in young boys with fragile X syndrome.

BACKGROUND: Repetitive behaviours are frequently observed in individuals with intellectual disability (ID). The present study examined the profile, inter-correlations and predictive correlates of repetitive behaviours in boys with fragile X syndrome (FXS), the leading inherited cause of ID. Specific child characteristics examined as predictors included anxiety, nonverbal cognition and autism social-affective symptomatology. METHOD: Participants were 39 boys with FXS (aged 6-10 years). Repetitive behaviours were measured using the Repetitive Behavior Scale - Revised (RBS-R) - a 43-item caregiver-report measure normed on individuals with ID. RESULTS: Restricted Interests and Sensory Motor behaviours were reported as most problematic for this sample of boys, whereas Self-injurious behaviours were less problematic. All subscales of the RBS-R were significantly inter-correlated. Nonverbal IQ was negatively related, whereas anxiety and social affective symptoms of autism spectrum disorder were positively related, to scores for Restricted Interests. Anxiety was also positively related to scores for Compulsive behaviours and Ritualistic Sameness behaviours. CONCLUSIONS: This study provides a preliminary description of repetitive behaviours in boys with FXS, which may form the groundwork for future research.

Domiciliary non-invasive ventilation in the elderly. Effective, tolerated and justified.

AIM: To determine if the long terms effects of non-invasive home mechanical ventilation (NIHMV) in the elderly are as beneficial as in younger subjects for a dedicated non-invasive ventilation unit in a tertiary referral hospital within the UK. PATIENTS AND METHODS: The study population included 256 patients who were successfully established on NIHMV between May 2009 and August 2013. Patients were divided into three groups according to age: group 1 (n=103) ≥75; group 2 (n=81) 65 -74; and group 3 (n=72) < 65 years of age. Initial assessments, both prior to starting NIHMV and at 12 month follow up were determined which included establishing the primary cause of respiratory insufficiency, measurement of arterial blood gas parameters, spirometry, overnight oximetry, and sniff nasal inspiratory pressure (SNIP) in those patients with neuromuscular disease. The number of hospital admissions in the year prior to starting NIHMV, and in the subsequent year, along with the number of days spent as an inpatient were ascertained as a measure of burden to local health care resources. Compliance with NIV at follow up, facilitated by recorded data within the ventilator software, was established along with an assessment of any reported side effects. RESULTS: Group 3 had the most profound abnormalities in lung function and blood gas parameters at initial assessment with a trend towards a higher number of acute admissions. In absolute terms, there was a greater decline in the number of admissions for subjects in group 2 after being established on NIHMV. Although more subjects in group 3 had chest wall deformities, COPD or bronchiectasis, this group had the lowest number of subjects with neuromuscular disease. Improvements in gas exchange were most pronounced for group 3 subjects despite no significant differences in the selected ventilator settings across the 3 groups. For neuromuscular patients, when measured, SNIP pressures were lowest in group 3. CONCLUSION: NIHMV was effective and tolerated for all three age groups. There was an improvement in measured patient centred endpoints across all three age groups, all of whom benefited equally.

Pregabalin as adjunctive therapy for partial epilepsy: an audit study in 96 patients from the South East of England.

INTRODUCTION: Pregabalin (PGB) was licensed in the EU in 2004 as an adjunctive therapy in partial epilepsy. It is also licensed for neuropathic pain and generalised anxiety. AIMS: To identify the clinical usefulness and side effects of add-on PGB in out-patient epilepsy clinics. METHODS: We performed an audit on 96 consecutive patients (44 male) prescribed PGB for refractory epilepsy. Mean follow-up, for those who remained on PGB, was 23 months (range 12-39 months). RESULTS: Fifty patients remained on PGB, 37 of whom reported clear improvement in seizure frequency. Among these 37 patients, 1 was seizure free for 15 months; 29 had a seizure reduction of >50%; and 7 improved by <50%. Eight patients reported a decrease in seizure severity without change in seizure frequency. Nine patients reported an incidental improvement in anxiety. Side effects were reported by 25 patients out of the 50 patients still on treatment: 12 reported drowsiness or tiredness, 8 weight gain, 7 dizziness, 2 headache, 2 cognitive side effects, 1 irritability, 1 itchiness, 1 anxiety, and 1 transient rash. Among the 46 patients who discontinued treatment, 9 had worsening of seizure frequency, 27 lack of efficacy and 9 intolerable side effects necessitating withdrawal (4 dizziness or drowsiness, 2 weight gain, 1 peripheral oedema, 1 pain in arms and legs, 1 irritability and cognitive side effects). One patient had a seizure related death (probably drowning) within 1 month of starting PGB. CONCLUSION: Pregabalin seems to be an effective and well-tolerated anti-epileptic drug when used as add-on treatment in patients with refractory partial epilepsy.

Episodes of care: theoretical frameworks versus current operational realities.

BACKGROUND: Fundamental changes in the structure of the health care industry have stimulated the need for improved definitions of output and for better methods of organizing utilization data into appropriate units. Although the "episode of care" concept has existed since the 1960s, its recognition as integral to the management of health care cost and utilization is relatively recent. Conceptually, episodes of care represent a meaningful unit of analysis for assessing the full range of primary and specialty services provided in treating a particular health problem. Proprietary episode software grouper products are currently being used by health care organizations for the purposes of provider profiling, clinical benchmarking, disease management, and quality measurement. DESCRIPTION OF EPISODE GROUPER SOFTWARE PRODUCTS: Four episode grouper products are described that use a computerized approach for developing episodes of care from administrative data. They are compared on several characteristics, including purpose, case-mix adjustment, comprehensiveness, and clinical flexibility. Their differences in episode construction, such as how the start points and endpoints of an episode are defined, are also delineated. CONCLUSIONS: Episode groupers are critical to the analysis of health care delivery, since they focus on the entire process of care. Although all the groupers reviewed have many strengths, much developmental work still needs to occur in order to standardize the measurement and operationalization of episodes of care as units of analysis. Furthermore, until the data sources used are more valid and reliable, they will at best remain gross screening measures of quality.

Developing a tool for analyzing medical care utilization of adult asthma patients in indemnity and managed care plans: can an episodes of care framework be used?

We evaluated the health care resource utilization between adult asthma patients in managed care organizations with those in indemnity plans using an episodes of care methodology. We also examined the importance of risk adjustment in explaining variation in resource utilization. Episodes were constructed using private insurance claims from 1992 to 1993. Bivariate and multivariate analyses were used to examine differences between managed care and indemnity plans on episode severity, resource utilization, and outcome measures (asthma-related hospitalizations and emergency room visits). Managed care plans showed higher resource utilization in terms of services and payments per episode compared with fee-for-service plans. Financial incentives to both providers and patients may have contributed to the higher utilization among managed care patients. An episodes of care methodology has potential to serve as a cost-effective "tool" in analyzing trends in medical care utilization within a health care plan. Validation of this methodology is necessary, however, before it can be used to compare trends in utilization across health plans.

Developing episodes of care for adult asthma patients: a cautionary tale.

An episodes of care methodology examines the contiguous cluster of services related to a particular health condition. We developed an episodes methodology for evaluating the quality of health care delivery to privately insured adult asthma patients. Computer algorithms were used for episode construction beginning with an index asthma diagnosis and ending with a final clinical event, yielding a sample of 30,553 episodes. Only service claims with an asthma diagnosis were assigned to an episode. We used a database of private insurance claims from 1992 to 1993. Disease staging served as the framework for evaluating episodes with similar severity and resource use. We found that episodes of care can be constructed from claims data and have the potential for use in physician profiling and as quality screens. Certain limitations in using this methodology suggest that caution needs to be exercised in applying this approach to evaluation of health care services.

Citizen perceptions of risks associated with moving radiological waste.

Much has been written about public support or opposition to the siting of hazardous waste facilities and more generally about concern for radioactive contamination. Much less has been written about the perceived risks of citizens' specific concerns about the transportation of radiological waste to temporary or permanent sites. This study reviews the existing literature in the area and presents new data on the subject from an Idaho survey. The new data indicates: (1) age, gender, and knowledge are the key variables predicting opposition to the transportation of such waste, (2) the primary concern among the opposing and unsure public is the planned use of trucks to move the TRU waste, and (3) respondents have high degrees of trust in officials who make decisions based on technical knowledge, are charged with the safety of transporting TRU waste, and who respond to mishaps. These attitudes need to be understood by policymakers and administrators when designing and implementing waste-transportation programs.

Sensory dysfunction associated with repetitive strain injuries of tendinitis and focal hand dystonia: a comparative study.

Repetitive strain injuries are reaching epidemic levels among workers who perform heavy schedules of rapid alternating movements (eg., computer programmers, data entry workers) or repetitive, sustained, coordinated movements (eg., editors, writers, salespeople). The purpose of this study was to determine if patients with repetitive strain injury demonstrated degraded sensory motor performance with their hands. Sixty age-matched adults were recruited, with 15 each assigned to a healthy adult control group, a healthy musician control group, a tendinitis group, or a focal dystonia group. Four sensory motor subtests from the Sensory Integration and Praxis Test were given to the subjects according to a standardized protocol. Using multiple one-factor analyses of variance in the parametric or nonparametric mode followed by post hoc pairwise testing, no significant differences were found between the healthy controls and the musician controls. On the test of kinesthesia, using the left hand, subjects with tendinitis performed significantly worse than controls and subjects with focal dystonia. Compared with controls, subjects with focal dystonia did significantly worse on graphesthesia and manual form perception (part 1 and part 2). Subjects with focal dystonia also did significantly worse than subjects with tendinitis when using the left hand on graphesthesia and manual form perception (part 2). When treating patients with repetitive strain injury, discriminative sensory motor skills must be carefully assessed and may need to be addressed as part of an effective treatment program.

Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment.

PURPOSE: The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence. PATIENTS AND METHODS: One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients. RESULTS: Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7). CONCLUSIONS: These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".

Screening for depression among a well elderly population.

This article describes a geriatric wellness program in which social work practitioners played a major role. The focus of this article is twofold: to examine the use of a telephone screening test for depression among a well elderly population and to compare the results of that screening with the clinical judgment of social workers. Overall findings indicated that a telephone screening instrument incorporating the Rand Mental Health Inventory and the Center for Epidemiological Studies Depression Scale was an efficient tool for assessing a population with a higher rate of major depression. Furthermore, the social workers identified many previously undetected cases of major depression, and a majority of people referred for treatment completed those referrals.

Predicting future functional status for seriously ill hospitalized adults. The SUPPORT prognostic model.

OBJECTIVE: To develop a model estimating the probability of an adult patient having severe functional limitations 2 months after being hospitalized with one of nine serious illnesses. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: 1746 patients (model development) who survived 2 months and completed an interview, selected from 4301 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT); independent validation sample of 2478 patients. MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 months after admission categorized as absence or presence of severe functional limitations (defined as Sickness Impact Profile scores > or = 30 or as activities of daily living scores > or = 4 [levels that require near-constant personal assistance]). A logistic regression model was constructed to predict severe functional limitation. RESULTS: One third (n = 590) of patients who were interviewed at 2 months had severe functional limitations. Changes in functional status were common: Of those with no baseline dependencies (not dependent on personal assistance), 21% were severely limited at 2 months; of those with 4 or more baseline limitations, 30% had improved. The patient's ability to do activities of daily living was the most important predictor of functional status. Physiologic abnormalities, diagnosis, days in hospital, age, quality of life, and previous exercise capacity also contributed substantially. Model performance, assessed using receiver-operating characteristic curves, was 0.79 for the development sample and 0.75 for the validation sample. The model was well calibrated for the entire risk range. CONCLUSIONS: Functional outcome varied substantially after hospitalization for a serious illness. A small amount of readily available clinical information can estimate the probability of severe functional limitations.

Comparison of direct and standardized testing of infected urine for antimicrobial susceptibilities by disk diffusion.

A total of 14,272 urine specimens were examined over one year to determine the validity of direct antimicrobial agent susceptibility testing against ampicillin, amoxicillin-clavulanic acid, cephalothin, gentamicin, norfloxacin, and trimethoprim. A comparison between direct and standardized disk diffusion tests was made for a total of 1,106 urine specimens containing > or = 10(5) organisms per ml in pure culture. There were 5,821 individual organism-antimicrobial agent challenges compared for the two testing methods, and there was complete agreement of susceptibility category in 5,492 comparisons (94.3%). Initially, discordant results were reduced from 5.7 to 2.1% when the intermediate category was considered susceptible. Intralaboratory variation was assessed by testing another 453 organisms by the standard National Committee for Clinical Laboratory Standards (NCCLS) method on two consecutive days; there was complete agreement in 96.1% of comparisons. When results of direct and standardized testing were simply classified as susceptible or resistant, there was 1.1% discordance. When simple same-day tests were used together with predictable patterns of susceptibility and resistance, 536 (48.5%) of 1,106 isolates could be identified satisfactorily to the genus or species level. For laboratory reporting purposes, the direct method is equivalent to the standard method when the urine being tested is infected with > or = 10(5) organisms of a single type per ml. The presence or absence of preexisting antimicrobial agents in urine did not appreciably influence the results. This procedure allows the earlier reporting of susceptibility results and facilitates less expensive identification of many organisms. Costs and benefits need to be determined in each institution.

Comparisons between dentist ratings and self-ratings of dental appearance in an elderly population.

Little is known about dental appearance in terms of the elderly population. The purpose of this paper is to compare self-reported dental appearance with dentist-rated appearance for individuals over 65. The subjects (N = 550) were participants in the Los Angeles based Medicare Screening and Health Promotion Trial. Most were female (57.3%), white (89.0%), and married (62.0%), with a mean age of 74.5 years. About one-third had incomes greater than $25,000. Results are based on a 45 minute telephone interview and onsite dental screening. Findings show that 40% of the self-ratings on a five point scale were higher than the dentist ratings, and 22% were lower. Bivariate analyses showed that both sets of ratings were related to dental status variables, self-reported health, and education. High self-ratings were also associated with being white and having a positive mental health status, while high dentist ratings were associated with patients who were younger, married, and who had higher income and social network scores. Comparison of results from two multiple regressions showed unique predictors for the self-ratings (marital status and GOHAI scores) and for the dentist ratings (sex and income). These discrepancies can raise barriers to effective treatment planning in the elderly, which could affect utilization and satisfaction.

Enrolling community physicians and their patients in a study of prevention in the elderly.

Enrollment of senior citizens in a community Medicare demonstration project to explore the efficacy of preventive health screening and health education was accomplished by using a two-stage process. This process consisted of initial communication with community physicians through the University of California at Los Angeles Clinical Faculty Association to establish credibility for the program. Physicians who agreed to participate then selected potential participants to receive, by mail, a description of the study and an introductory letter from their own physician. Followup and actual enrollment of participants was then handled by the study team. A total of 57.6 percent of the elderly people approached agreed to participate in the study.

Lingually displaced mandibular canine teeth: orthodontic treatment alternatives in the dog.

Lingual displacements of mandibular canine teeth often occur following retention of deciduous canine teeth. This condition often results in trauma of occlusion to the lingual aspect of the maxillary canine tooth and the further development of a periodontal pocket or an oronasal fistula. This condition can be corrected using orthodontic appliances. The purpose of this paper is to discuss and illustrate the various alternatives available for correction of this common malocclusion in dogs.

Appropriateness of acute medical care for the elderly: an analysis of the literature.

Over the past 30 years, an explosion in health care expenditures has occurred. Prior to 1960, health care accounted for 4.4% of the U.S. Gross National Product; today it is 11%. Before rational solutions to controlling this rise can be proposed, we must determine whether the care that we are currently paying for is appropriate to the needs of the elderly. This paper analyzes the literature regarding appropriateness of acute care provided to the elderly. We identified 17 articles that explicitly cited appropriate or inappropriate care (including under-, over- and misuse) provided in hospital and ambulatory settings and for procedures, and 19 articles that presented data on the appropriateness of medication use in the elderly. Virtually every study included in this review found at least double-digit levels of inappropriate care. Perhaps as much as one-fifth to one-quarter of acute hospital services or procedures were felt to be used for equivocal or inappropriate reasons, and two-fifths to one-half of the medications studied were overused in outpatients. The few studies that examined underuse or misuse of services also documented the existence of these phenomena. This was especially true for the ambulatory care of chronic physical and mental conditions and concerned the use of low-cost technologies (visits, preventive services, some medications). Thus, we conclude that there appears to be a substantial problem in the matching of acute services to the needs of elderly patients. This mismatch occurs both in terms of overuse and underuse, at least for areas where research has been conducted.

Comparison of in vivo effects of intravenous infusion of N-formyl-methionyl-leucyl-phenylalanine and phorbol myristate acetate in rabbits.

Comparison of the physiologic responses in rabbits to the intravenous infusion of two polymorphonuclear neutrophil (PMN) activators, N-formyl-methionyl-leucyl-phenylalanine (FMLP) and phorbol myristate acetate (PMA), has revealed marked differences in kinetics for activation between these agents. FMLP infusion was associated with maximally increased respiratory rates (RR), a maximally decreased mean blood pressure (MBP), and a maximally decreased absolute granulocyte count (AGC), all within the first 5 min after infusion. However, there were no significant differences between RR, MBP, and AGC of FMLP-treated animals and controls, 15 min postinfusion and after. On the other hand, PMA did not cause significant changes in RR or MBP until 30 min and 2 h postinfusion, respectively. Previous work has demonstrated that both FMLP and PMA stimulate the PMN metabolically in vitro via the same respiratory burst enzyme, NADPH oxidase, but that each of these activators demonstrates kinetics which are different from the other. Thus, these data from an in vivo study support previous in vitro findings and offer further evidence that the neutropenia and cardiopulmonary alterations following intravenous infusion of FMLP and PMA may be caused by metabolic activation of the blood PMN.