Growing up with idiopathic short stature: psychosocial development and hormone treatment; a critical review.

To facilitate decisions on interventions in medically referred children with idiopathic short stature, the research on psychosocial functioning of these children, possible risk and protective factors influencing adaptation, and effects of hormone treatment were reviewed. Parents ranked the behaviour of their children on average between normal and below normal. The magnitude of these deviations varied from small to large. Little is known about the children's self-perceived psychosocial functioning. Some risk factors were found: being teased, being juvenilised, being a boy, having a younger but taller sibling, low intelligence, and low socioeconomic status. There have been few studies on the impact of protective factors including temperament, coping strategies, and social support. On average, hormone treatment did not improve psychosocial functioning. The research shows the advantages and disadvantages of hormone treatment that must be considered when choosing a suitable intervention. It is suggested that psychosocial adjustment can be improved by focusing on factors other than height alone.

A neurocorrective approach for MMPI-2 use with brain-damaged patients.

Conventional administration of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) to aetiologically distinct brain-damaged out-patients (n = 137) revealed significant indications of psychological maladjustment. An adjustment for the endorsement of aetiology-specific items pertaining to traumatic brain injury (TBI), stroke, and whiplash was considered necessary, however, because these items may represent potentially valid symptoms or manifestations of neurological damage or dysfunction. These so-called neurologically relevant items (NRIs) were identified in a previous study. With this corrective approach, based on the complete MMPI-2 item pool, it was shown that T-score elevations could at least in part be attributed to symptoms associated with brain injury, regardless of the type of brain damage. Similarly, after prorated correction for the endorsement of NRIs, code-typing appeared to be substantially changed with respect to both occurrence and content of the MMPI-2 defined code-types. The validity of the NRI concept was supported by comparing NRI/non-NRI endorsement ratios of traumatically brain-injured patients with those of non-neurological patients, and with those having anxiety and somatoform disorders. To prevent unjustified interpretations when administering the MMPI-2 to brain-damaged patients, an adjustment procedure for NRI-endorsement is proposed, and difficulties in interpretation are discussed.

The identification of neurologically relevant items in the MMPI-2.

The assessment of personality and (mal) adjustment after brain damage is regarded as an important aspect of rehabilitation. However, the administration of widely used self-report questionnaires, such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), is restricted because of the danger of overscoring psychopathology and personality disorders. This is due to the inclusion of items reflecting manifestations of neurological dysfunction. Earlier investigations revealed variable neurologically relevant items (NRIs), within and between discrete cerebral aetiologies for the MMPI as well as the first part of the MMPI-2. In this study, 10 neuropsychologists, 10 neurologists, 10 psychiatrists, and 10 physiatrists identified NRIs in the complete MMPI-2. An item was considered to be an NRI based on professional expertise as well as type of brain damage. Based on a substantial inter-rater agreement index, four sets of clinical relevant NRIs were selected: one for brain damage in general and three partially overlapping sets for stroke, traumatic brain damage, and whiplash. Thus, the findings of this study unveil items which may indicate bona fide symptoms or manifestations related to neurological damage or dysfunction, rather than just reflecting psychopathology or personality disorders. It is advocated to develop an interpretative approach to correct for the impact of these NRIs on MMPI-2 scores.

Towards a disability-oriented epidemiology of traumatic brain injury.

The aim of this study was to investigate the value of using a disability-oriented approach to the epidemiology of traumatic brain injury (TBI) in order to improve health administration by preventing long-term sequelae. The epidemiology of disease was established by registration system of inpatients which covers more than 99% of all hospital admissions in The Netherlands. Some international differences and national trends are discussed. The disability-related epidemiology was investigated by means of structured interviews, 3-7 years after the injury, in a clustered sample of 51 patients with major TBI according to the ICD-9-CM. The survey included evaluation scales such as the Sickness Impact Profile, the Barthel Index, and a Disability Rating Questionnaire. Concerning the disease-related epidemiological data, the overwhelming majority of all TBI patients went home, which suggests good recovery. Nevertheless, the disability-oriented research revealed long-term situational, cognitive and behavioral disabilities in at least 67% of the major-TBI population, whereas only 10% received any rehabilitation services at all after the acute-care period. It is concluded that preventive measures and a comprehensive service for brain injury survivors should be based both on disease and disability-oriented data.

Hands-on training in health district management.

PIP: In 1985 in Zaire, a 12-week training course began in Kasongo district to prepare physicians to use sound management of primary and secondary health services, supervision of health centers, and commitment to team work to operate districts in an integrated way. Only 1 new physician trainee was accepted every 4 weeks. During the first week, trainees observed work at an outpatient clinic for 2-3 hours/day to learn about the links between the primary and secondary levels of health care. During the second week, they observed staff at an urban health center in Kasongo city so they could become familiar with strategies for diagnosis and treatment in curative consultations and with instructions for follow-up. During the third week, the trainees returned to the outpatient clinic to practice interviewing patients. During the fourth week, they observed work in a rural health center and in remote villages. During the second 4-week period, trainees worked in a hospital department of their choice to learn how to use files and to evaluate quality of care. They visited health centers 1-2 times/week to examine supervisory techniques of different resident physicians. Trainees were part of the health team during the third 4-week period. They were responsible for a hospital department and supervised health centers under a resident physician. The trainees also attended management committee meetings addressing quality of care, staff management, and feedback from health center supervisions. The cost for this health district management training was US $100/trainee. Between mid-1985 and mid-1988, 18 physicians underwent this training. 12 of these physicians are now working in health districts in Zaire. A follow-up survey in 1995 showed that most trainees were applying the requisite skills and knowledge acquired during the training. Further supervision or self-training, involving team analysis of problems and possible solutions, are needed. Factors contributing to the course's success include: an integrated health system under the direction of a health team, a large enough team to do student training but small enough to maintain communication, and active participation of trainees.^ieng

Screening for Trypanosoma brucei gambiense antibodies with the Indirect Fluorescent Antibody Test (IFAT). Effect of age and previous treatment.

This paper reports on some of the findings of a longitudinal multi-round investigation into the predictive power of early signs and symptoms of human African trypanosomiasis caused by T.b. gambiense, in the Rural Health Zone of Kasongo (Maniema, Zaire). It assesses the importance of the effect of age and a history of previously treated sleeping sickness on serological positivity as measured by the Indirect Fluorescent Antibody Test (IFAT), used as a screening test. The impact of including age and a history of previous sleeping sickness as part of the screening process is discussed in terms of sensitivity and positive predictive value. Including weak serological positivity among the screening criteria does not appear to improve the sensitivity of the IFAT test in this setting.

[Typology and performance of first-referral hospitals in sub-saharan Africa]. / Typologie et performances des hopitaux de premier recours en Afrique sub-saharienne.

This descriptive study provides a typology of first referral level hospitals in sub-Saharan Africa. Data are provided on 88 mainly non-governmental hospitals in 25 African countries. They were obtained through a mail survey. The first aspect discussed is the place of the hospital within the spatial organization of the health care district: population served and other health units. This makes it possible to classify the hospitals in three groups. The analysis of the role of the hospital in the management of the district and the support of the peripheral network is based on information about the formal relations of authority, the participation of the hospital in training and supervision, in provision of drugs and in the financial management of the district. This is followed by a description of the human and other resources available in the hospitals, the type and organization of care provided, as well as the performances in terms of outpatient care, inpatient care and technical interventions. Finally, the available information on expenditure and sources of financing is presented.

[The initiative for a risk-free motherhood: which perspectives?]. / L'initiative pour une maternité sans risque: quelles perspectives?

The "Safe Motherhood Initiative" started off with a first conference held in Nairobi in February 1987. In 1989, several conferences were organised throughout the world which led to a new current of opinion in favour of maternal health improvement. Governments, decision markers and aid agencies have been called upon to support such Initiative. In this paper, we review the main characteristics of the Safe Motherhood Initiative and analyse two main constraints which were insufficiently discussed during the conferences. The first one is the need to increase the efficiency of the existing health system. The second one is the problem which arises from poor acceptability by the populations of certain health activities promoted by the Initiative. By giving various examples, we describe how these factors may restrict its expected results. Proposals are made to increase the efficacy of the programmes and of activities promoted by the Initiative and to ensure its mid-range continuation. The authors suggest that specific attention and more resources have to be given to achieving specific operational researches, by taking into account the health behaviour of the populations, the characteristics of the existing health services and the resources available. Such research will lead to improved maternal health activities.

Haemoglobin measurement: the reliability of some simple techniques for use in a primary health care setting.

The reliability of five simple techniques for the estimation of blood haemoglobin levels was studied under laboratory conditions. The methods tested were the Sahli technique, the Tallqvist method, and the Lovibond comparator with undiluted blood, blood diluted in Drabkin solution, and blood diluted in modified Drabkin solution. The Lovibond comparator technique using undiluted blood was satisfactory in terms of precision and accuracy, and seems suitable for the monitoring of individual patients and for screening for anaemia. The other techniques were less reliable.A detailed procedure was worked out for estimation of the number of screening errors that can be expected with each of these techniques in any epidemiological situation.

Isolation and identification of mercapturic acid metabolites of phenyl substituted acrylate esters from urine of female rats.

The urinary mercapturic acid excretion by female rats of methyl atropate (alpha-phenyl methyl acrylate) and methyl cinnamate (beta-phenyl methyl acrylate) has been studied. On the basis of the structures of these mercapturic acids the conclusion can be drawn that these compounds arise from a conjugation of glutathione with the acrylic esters in a Michael fashion. Previous administration of (tri-orthotolyl) phosphate (TOTP), a carboxy esterase inhibitor, enhances the capacity of the acrylate esters to alkylate glutathione in vivo. The amount increased from 1.5 to 22.8% of dose (1.0 mmol/kg) for methyl cinnamate and from 10.4 to 14.8% of dose (0.2 mmol/kg) for methyl atropate. Upon inhibition of the esterase activity the major actual mercapturic acid is a conjugate of the acrylate in which the ester function is retained. In the absence of an esterase inhibition the excreted mercapturic acid is a formal conjugate of the free acrylic acid (Fig. 1). No mercapturic acids could be detected which might arise from glutathione conjugation of a, beta-epoxyesters. Such epoxides are potential primary metabolites of unsaturated esters. They were not detected by in vitro experiments. Therefore, the intermediacy of glycidic esters in the biotransformation of these acrylic esters may be considered as highly unlikely.