'Always the guiding hand': parents' accounts of the long-term implications of developmental co-ordination disorder for their children and families.

BACKGROUND: There has been little investigation of the long-term implications of developmental co-ordination disorder (DCD) and, particularly, its impact on families. This is despite the prevalence of the disorder (4.5% to 6%) of the child population, and the high rates of referral to occupational therapy departments. The study reported here was part of an evaluation of an innovative screening clinic for the assessment of children with DCD. METHODS: Within the case study approach of the evaluation, questionnaires, including open-end questions, were sent to 70 families. All had attended the screening clinic 6 years earlier and had little subsequent contact with the occupational therapy service. Semi-structured interviews were held with 12 mothers who volunteered to participate. These enabled specific issues raised in the questionnaires to be explored in greater depth. Interviews were audiotaped and full text transcripts produced for analysis. RESULTS: Over half the questionnaires were returned despite the length of time elapsed since hospital contact. Parents who responded reported a high persistence of problems in their children. Difficulties spanned motor and academic performance, emotional/behavioural responses and social interaction. Twenty-eight children (80%) of respondents were reported as having difficulties in three or more areas. Bullying was a commonly identified problem. At interview mothers spoke at length about their experiences and reported feeling stressed and distressed. Mothers reported a lack of support and expressed feelings of isolation. They said that their time investment in their child with DCD had pronounced effects on themselves and other family members. Specifically they highlighted time spent fighting the system, primarily for educational support. CONCLUSIONS: The study suggests a need for occupational therapists to reframe their current ideas regarding service provision, with improved support for families, increased interagency working and more service-user involvement.

Local immune responsiveness following intravaginal challenge with Candida antigen in adult women at different stages of the menstrual cycle.

Recurrent vulvovaginal candidiasis (RVVC) is a significant problem in women of childbearing age and is most often caused by Candida albicans that asymptomatically colonizes mucosal tissues. Although some form of local immune dysfunction is postulated to precipitate bouts of RVVC, the normal protective vaginal host response to C. albicans is poorly understood. In an effort to stimulate the natural adaptive response to yeast in healthy women without a history of VVC, commercial Candida skin test antigen was introduced intravaginally and changes in cytokines/immunomodulators were monitored in vaginal lavage fluid pre- and post-antigen challenge. In an earlier pilot study using small numbers of women without controlling for stages of the menstrual cycle, we reported elevated cytokines in vaginal secretions of antigen challenged women. The present study, however, that employed a similar design in a large number of women during each stage of the menstrual cycle showed no evidence of local immune stimulation, including changes in Th and proinflammatory cytokines, IgE, histamine, and prostaglandin, despite a natural modulation of vaginal cytokines over the course of the menstrual cycle. Taken together, these results suggest that either some form of vaginal immunoregulation/tolerance is evident in response to yeast or that more advanced clinical designs are required to detect the normal protective vaginal response to C. albicans.

Digital examination compared to trans-perineal ultrasound for the evaluation of anal sphincter repair.

OBJECTIVE: To assess the adequacy of a third- or a fourth-degree laceration repair by comparing digital and trans-perineal ultrasound measurements. METHOD: During a 4-year period, 34 subjects without prior history of anal sphincter injury or fecal incontinence underwent ultrasound measurements of external anal sphincter muscle diameter and perineal length, which were compared to measurements obtained by digital examination. RESULTS: Pearson's correlation coefficients for comparing the digital external sphincter examination to trans-perineal ultrasonography, and the digital perineal examination to trans-perineal ultrasonography were 0.88 and 0.40, respectively. Patients (n=4/34) whose external sphincter was identified as less than 1 cm by digital examination were found to have an external sphincter diameter of less than 1 cm by trans-perineal ultrasound. CONCLUSION: The digital perineum examination is a reliable method of measuring the external sphincter thickness and perineal body length immediately after primary repair.

Persistence of delayed hypersensitivity following transurethral collagen injection for recurrent urinary stress incontinence.

Transurethral collagen injection is both safe and effective when used for the treatment of genuine stress urinary incontinence. It is associated with a minimal inflammatory response, and virtually no foreign body reaction. Most allergic reactions occur within 72 hours of treatment (immediate hypersensitivity). Although uncommon, delayed hypersensitivity reactions may occur and it is advisable to administer a collagen skin test 30 days prior to the procedure. Adverse effects may cause long-term sequelae, such as severe trigonal tenderness, urgency, frequency, hematuria, urinary retention and persistent stress urinary incontinence. A case of a prolonged delayed hypersensitivity reaction following negative collagen skin testing after transurethral collagen injection is presented. Treatment of stress incontinence could not be initiated until symptoms decreased significantly after 1 year.

Nice lessons to be learned.

OBJECTIVES: This study examined users' perceptions of the role and value of the Scottish Health Purchasing Information Centre (SHPIC) from 1995 to 1998. METHODS: Questionnaires and interviews were used to gather data from Scottish GP fundholders and health board managers at two stages. RESULTS: Initially, purchasers sought help in identifying the most relevant information. By 1997, while some appreciated the clinical and cost-effectiveness information produced, others were critical of lack of timely production and apparent lack of cooperation between agencies. CONCLUSIONS: New U.K. agencies can learn from SHPIC's problems, specifically in producing clear, coordinated, timely, independent, and well-marketed information with implementation strategies. POLICY IMPLICATIONS: It is important to evaluate the impact of agencies to produce and disseminate evidence-based information, even if this has to be done pragmatically rather than as an outcomes-based assessment. Evidence from evaluations can inform direction and strategy for existing and new agencies.

Analysis of the CD4 protein on human vaginal T lymphocytes.

PROBLEM: Although T lymphocytes at the human vaginal mucosa have been partially characterized, there remains a paucity of information regarding cell-mediated immune mechanisms at this mucosal site. In mice and humans, there are several phenotypic distinctions between vaginal T lymphocytes and those in the peripheral circulation. Recently, we observed as well that the N-terminus of the CD4 protein on murine vaginal T lymphocytes is atypically expressed compared to its systemic counterpart, and that the atypical expression extends to the mRNA level. METHOD OF STUDY: The purpose of this study was to evaluate the CD4 protein on human vaginal T lymphocytes by flow cytometry and RT-PCR. RESULTS: Results showed that, in contrast to mice, the CD4 protein on human vaginal and peripheral blood T lymphocytes are similar at both the molecular and protein levels. CONCLUSIONS: These results indicate that based on several differences between human and mouse vaginal T cells, caution is urged when using mice as a model to study human vaginal immunity.

Health care management: models for evidence-based practice.

Presents models suggesting how research evidence can best be operationalised within health care commissioning. Models were derived from data gathered from surveys of Scottish health board managers and GP fundholders regarding the use of information in commissioning from 1995 to 1997. Feedback on the models was obtained subsequently from practitioners in 1998. Two models, one for health board managers and the other for GPs, are presented. These include critical success factors in achieving evidence-based commissioning and factors that are likely to predispose and precipitate evidence-based practice. Given a culture demanding transparency, accountability and continuing improvement, the models provide tools for reflection, evaluation and planning. In addition, they identify a pragmatic role for managers in evidence-based commissioning and provide a framework for audit.

Cystoscopic fistulography: a new technique for the diagnosis of vesicocervical fistula.

BACKGROUND: Most fistulas communicating with the bladder are large enough to be diagnosed easily, or small enough to close spontaneously without clinical sequel. A vesicocervical fistula is an uncommon event and may be difficult to diagnose. TECHNIQUE: During an operative cystourethroscopy procedure, suspicious areas of the bladder can be probed with a cone tip catheter and injected with contrast dye to visualize the suspected fistula communicating with the bladder. EXPERIENCE: This technique was employed when a double dye test, an intravenous urogram, a cystogram, a computed tomography scan, and a hysterogram failed to localize the fistulous tract in a patient who was 3 weeks postpartum after a repeat cesarean with complaint of persistent urinary incontinence. CONCLUSION: Cystoscopic catheterization of suspicious lesions in the bladder may visualize an otherwise elusive fistulous tract.

Health services can be cool: partnership with adolescents in primary care.

Young people's health is giving rise to increasing concern. However, despite recent government emphasis on patient involvement and partnership, little discussion has occurred concerning how this may be achieved with younger age groups in primary care. Here we outline issues relating to adolescents' health and characteristics of current provision. These are considered in the context of innovative services that have incorporated adolescents' views. Finally, we discuss the challenge of establishing a partnership with adolescents and propose strategies for achieving this.

Is this satisfaction survey satisfactory? Some points to consider in their planning and assessment.

Measuring patient satisfaction is one of the commonest evaluation activities in the NHS. The main aim of the article is to highlight some of the most important aspects of planning, undertaking and critically appraising satisfaction surveys. Key areas considered include: survey aims; definition of concerns; nature of survey populations; methods; interpretation of results; and outcomes and implementation.

Staff views on orthopaedic patients' accommodation.

Alternative accommodation to traditional wards may be suitable for some orthopaedic patients. Doctors and nurses in this study had different views about patient accommodation. Little reference to patient choice was made by either doctors or nurses. Further research is needed on different staff groups regarding factors influencing discharge decision-making.

More than a sympathetic ear? A report on the first year of a writer in residence in a unit for young, physically disabled people.

OBJECTIVE: To describe a writer in residence scheme and report the views of patients and staff. DESIGN: Qualitative study including interviews with patients, a questionnaire survey of staff, and dialogue with the writer. SETTING: A unit for young people with physical disability. SUBJECTS: A convenience sample of patients admitted to the unit and members of the multidisciplinary rehabilitation team. INTERVENTION: A writer in residence working 15 hours per week in the unit. RESULTS: A small number of patients worked regularly with the writer and this led to the publication of a play, short stories and poems. Patients described wide ranging benefits including improvements in mood state. Staff regarded the writer in residence scheme as enhancing their treatment and care and thought it helpful in addressing their own psychological needs. The writer saw herself as a catalyst 'for the creativity of others'. CONCLUSION: Such schemes have an important role to play in rehabilitation settings.

Stress urinary incontinence due to prescription medications: alpha-blockers and angiotensin converting enzyme inhibitors.

BACKGROUND: Several antihypertensive medications affect lower urinary tract function and may cause urinary incontinence. CASE: A 59-year-old woman on doxazosin mesylate for control of her hypertension presented with stress urinary incontinence. Because this drug is known to cause loss of urethral tone leading to stress incontinence in some patients, she was switched to enalapril maleate, an angiotensin converting enzyme inhibitor. Her incontinence improved on the new medication, but she developed a persistent dry cough that continued to cause episodic stress incontinence. Because a persistent cough is a known side effect of angiotensin converting enzyme inhibitors, her medication was changed to a calcium channel blocker, amlodipine besylate. Her cough resolved, and her stress incontinence was no longer a clinical problem. CONCLUSION: Gynecologists should be aware of the unexpected side effects of medications on the lower urinary tract.

Stroke services in general practice--are they satisfactory?

BACKGROUND: The contribution of general practice and primary care teams to stroke care has received surprisingly little attention despite research evidence on the importance of coordinated care. AIM: To determine general practitioners' (GPs') and their patients' satisfaction with hospital and community services for stroke patients in Grampian Region, Scotland. METHOD: A questionnaire survey of 138 stroke patients and their GPs was carried out six weeks after each patient was discharged home between June 1995 and January 1996. Outcomes measured were GP and patient satisfaction with services, Barthel Index, Hospital Anxiety and Depression scores, London Handicap Score, and Homsat and Hospsat scores (satisfaction with stroke services). RESULTS: Response rates of 95% (131) for GPs and 91% (125) for patients were obtained. GPs and patients were generally satisfied with services. Stroke patients were more likely to have had contact with their GP than with any other service. Adverse comments from GPs focused on problems with hospital discharge letters. At six weeks, patients received an average of 2.5 community services and 1.5 hospital services, but there was wide variation across disability groups. CONCLUSIONS: Levels of satisfaction were high, but the wide range and variation in services used by patients emphasized the complexity of the primary care of stroke patients; the need for coordination, review and effective links with hospital; and the key role of the GP.

The role of colpocleisis with urethral lengthening in transsexual phalloplasty.

OBJECTIVE: Transsexual surgery is an unique area of rarely performed surgery. This study examines factors that have significance in the prevention of major morbidity in this unusual surgery. The role of the gynecologist in the psychologic, endocrine, and operative management is presented. STUDY DESIGN: Initial operations were complicated by fistulas at the urethra-to-phallus anastomosis site. After reviewing these complications, we modified our approach to include a two-stage procedure allowing for healing before microsurgery and sparing of the anterior vaginal wall during vaginal hysterectomy and colpocleisis. By sparing the anterior vaginal wall, we were able to better extend the urethra for later phallus attachment. RESULTS: Using the two-stage procedure at colpocleisis allowed a significant reduction in the fistula rate. (p = 0.0087) with the effective elimination-fistulas, the use of stiffeners during phalloplasty for better functional results is possible. CONCLUSION: Extending the urethra during colpocleisis allows for better healing and significantly decreased fistula formation. Proper blood supply for microvascular surgery and adequate tissue for the anastomosis site contribute to better results.