Comparative Analysis of Radiotherapy Linear Accelerator Downtime and Failure Modes in the UK, Nigeria and Botswana.

The lack of radiotherapy linear accelerators (linacs) in low- and middle-income countries (LMICs) has been recognised as a major barrier to providing quality cancer care in these regions, together with a shortfall in the number of highly qualified personnel. It is expected that additional challenges will be faced in operating precise, high-technology radiotherapy equipment in these environments, and anecdotal evidence suggests that linacs have greater downtime and higher failure rates of components than their counterparts in high-income countries. To guide future developments, such as the design of a linac tailored for use in LMIC environments, it is important to take a data-driven approach to any re-engineering of the technology. However, no detailed statistical data on linac downtime and failure modes have been previously collected or presented in the literature. This work presents the first known comparative analysis of failure modes and downtime of current generation linacs in radiotherapy centres, with the aim of determining any correlations between linac environment and performance. Logbooks kept by radiotherapy personnel on the operation of their linac were obtained and analysed from centres in Oxford (UK), Abuja, Benin, Enugu, Lagos, Sokoto (Nigeria) and Gaborone (Botswana). By deconstructing the linac into 12 different subsystems, it was found that the vacuum subsystem only failed in the LMIC centres and the failure rate in an LMIC environment was more than twice as large in six of the 12 subsystems compared with the high-income country. Additionally, it was shown that despite accounting for only 3.4% of the total number of faults, linac faults that took more than 1 h to repair accounted for 74.6% of the total downtime. The results of this study inform future attempts to mitigate the problems affecting linacs in LMIC environments.

Dietary intake of 9-10-year-old and 11-12-year-old children in Liverpool.

OBJECTIVE: To describe the eating habits of children in Liverpool and compare two age groups that bridge the transition from primary to secondary school. DESIGN: Two cross-sectional studies carried out one year apart using a food intake questionnaire that records whether or not each child claims to have eaten specific marker foods on the previous day. SETTING: Primary and secondary schools in Liverpool. SUBJECTS: Six hundred and forty-nine children aged 11 or 12 years and 3556 children aged 9 or 10 years. RESULTS: Fewer older children ate breakfast (68-82%), especially the girls, and not eating breakfast was associated with eating on the way to school in the younger children. More of the older girls ate nothing at breakfast or on the way to school. Overall, the less desirable foods were reported to have been eaten by more children, of both ages, than the more desirable foods. Fruit, however, was mentioned by most children (69-77%) but the next 10 foods mentioned by most children were all less desirable ones. Only 31% of primary and 21% of secondary children ate both fruit and vegetables but 23% of primary and 26% of secondary children ate neither fruit nor vegetables. Overall, more of the girls of both age groups claimed to have eaten foods that would normally be encouraged. CONCLUSIONS: Food choice changes appreciably between primary and secondary school and, in some key respects, for the worse. In particular, far more children of both age groups need to be eating fruit and vegetables every day.

Working with women's groups to promote health in the community using the Health Analysis and Action Cycle within Nepal.

The Health Analysis and Action Cycle was conceived as an empowering approach that enables women to review their health and environmental situation. It considers health in its socioenvironmental context and does not focus only on the biomedical dimension. The women are able to consider their own beliefs surrounding health and illness in a nonthreatening way and to plan and take action for themselves. The approach was first developed for use in Nepal among literate women's groups; later, a more visual approach was adapted from this for nonliterate groups. This second step was felt necessary due to the high level of illiteracy (75%) among women. This article will provide information on the steps involved in the Health Analysis and Action Cycle and some of the outcomes of this approach.

Identification of a pathogenicity island, which contains genes for virulence and avirulence, on a large native plasmid in the bean pathogen Pseudomonas syringae pathovar phaseolicola.

The 154-kb plasmid was cured from race 7 strain 1449B of the phytopathogen Pseudomonas syringae pv. phaseolicola (Pph). Cured strains lost virulence toward bean, causing the hypersensitive reaction in previously susceptible cultivars. Restoration of virulence was achieved by complementation with cosmid clones spanning a 30-kb region of the plasmid that contained previously identified avirulence (avr) genes avrD, avrPphC, and avrPphF. Single transposon insertions at multiple sites (including one located in avrPphF) abolished restoration of virulence by genomic clones. Sequencing 11 kb of the complementing region identified three potential virulence (vir) genes that were predicted to encode hydrophilic proteins and shared the hrp-box promoter motif indicating regulation by HrpL. One gene achieved partial restoration of virulence when cloned on its own and therefore was designated virPphA as the first (A) gene from Pph to be identified for virulence function. In soybean, virPphA acted as an avr gene controlling expression of a rapid cultivar-specific hypersensitive reaction. Sequencing also revealed the presence of homologs of the insertion sequence IS100 from Yersinia and transposase Tn501 from P. aeruginosa. The proximity of several avr and vir genes together with mobile elements, as well as G+C content significantly lower than that expected for P. syringae, indicates that we have located a plasmid-borne pathogenicity island equivalent to those found in mammalian pathogens.

The use of formal and informal health care by female adolescents in eastern Nepal.

I am presenting the background and interim results of an ongoing study in Eastern Nepal where at present the adolescent females do not use the formal health sector to the same extent as men. Suggested reasons for this include lack of awareness (literacy rates among women are 17%), lack of access, lack of time, and the cost and the quality of services offered. Women are more likely to visit traditional health practitioners, and very little research has been done to find out why this is the case. I also examine the access of rural adolescent females to health services and the policy process. The researcher involves the women in the research so that they can actively participate in the decision-making process and in setting health priorities. The research is based on a reconstituted form of participatory rural appraisal (PRA) known as participatory appraisal of needs and development of action (PANDA). This is a framework which has been developed out of PRA and has been used in developing countries to enable local people to obtain, share, and analyze their life conditions and to plan and act according to that knowledge.

Reliability of post-mortem chart diagnoses of schizophrenia and dementia.

The reliability of psychiatric diagnosis has a direct effect on the validity of post-mortem analyses of neuropathological data, yet little is known about the reliability of retrospective diagnostic procedures which rely on review of medical records. In this paper, we report on the reliability of DSM-III-R psychiatric diagnoses assigned by a pool of 8 raters to a set of 106 state hospital charts of elderly, chronic patients who had died while institutionalized and were autopsied. Diagnoses were grouped by general diagnostic class, and Kappa coefficients computed for agreement among raters, as well as for agreement between ultimate consensus diagnoses and those made while subjects were living. Interrater agreement for those diagnoses that occurred most frequently in this sample (e.g. Schizophrenia and Dementia) was excellent, and comparable to the the agreement observed for ratings of live patients. Interrater agreement for less frequently occurring diagnoses (e.g. Mental Retardation, Mood Disorders, other non-Schizophrenic Psychoses) ranged from excellent to poor. We found high agreement between our rates diagnoses and those assigned by state hospital personnel while patients were living, although post-mortem review produced lower rates of diagnosis of both schizophrenia and Alzheimer-type dementias. Overall, results suggest that the reliability of chart review diagnosis is comparable to that obtained from interviews of live patients when experienced raters are used and diagnostic base rates are high enough to produce stable estimates of reliability.

Molecular characterization of the Pseudomonas syringae pv. pisi plasmid-borne avirulence gene avrPpiB which matches the R3 resistance locus in pea.

An avirulence gene (designated avrPpiB) from race 3 of Pseudomonas syringae pv. pisi was cloned and sequenced. The gene corresponded to a single open reading frame of 831 nt identified by transposon mutagenesis and subcloning. This ORF encodes a predicted hydrophilic protein of 276 amino acids (MW 31,300). It effects the expression of a resistance mechanism governed by a single genetic locus in pea. Cosegregation of resistance at the R3 locus of pea was observed towards race 3 and a transconjugant carrying the cloned avrPpiB gene according to the predicted 3:1 ratio of resistant:susceptible F2 progeny from a cross between Jade (R3 R3) and Kelvedon Wonder (rr) cultivars. DNA hybridization studies showed avrPpiB to be plasmid-borne in race 3 and suggested the presence of other alleles on one of the endogenous plasmids of races 1 and 7. Disruption of the avrPpiB allele of race 1 and its complementation confirmed its behavior towards pea cultivars expressing the R3 locus. Homologs of avrPpiB were detected in P. syringae pv. phaseolicola, P. syringae pv. maculicola, and P. syringae pv. tomato. The presence of avrPpiB homologs in P. syringae pv. phaseolicola does not match any gene-for-gene pattern of interaction with bean cultivars.

A pedigree series for mapping disease genes in bipolar affective disorder: sampling, assessment, and analytic considerations.

A series of 57 extended pedigrees with high density of bipolar affective disorder is described. Ascertainment and diagnostic procedures are documented and simulation studies to assess statistical power are carried out. The pedigrees, obtained in the US and Israel, are comprised of 1508 adult individuals with best estimate consensus diagnoses (12-71 relatives per pedigree), 490 of whom (including 401 sib pairs) meet criteria for a conservative disease definition (bipolar disorder or recurrent major depression). Cell lines have been established on 1324 of these individuals. Statistical power to detect linkage with lod score analysis, assuming autosomal dominant transmission and highly polymorphic DNA markers, is nearly 100% for alpha (proportion of linked families) = 30%, and 75% for alpha = 20%. This is the largest bipolar pedigree series reported to date; its unique features make it amenable to various gene detection techniques.

Functional homologs of the Arabidopsis RPM1 disease resistance gene in bean and pea.

We showed that a bacterial avirulence (avr) gene function, avrPpiA1, from the pea pathogen Pseudomonas syringae pv pisi, is recognized by some, but not all, genotypes of Arabidopsis. Thus, an avr gene functionally defined on a crop species is also an avr gene on Arabidopsis. The activity of avrPpiA1 on a series of Arabidopsis genotypes is identical to that of the avrRpm1 gene from P.s. pv maculicola previously defined using Arabidopsis. The two avr genes are homologous and encode nearly identical predicted products. Moreover, this conserved avr function is also recognized by some bean and pea cultivars in what has been shown to be a gene-for-gene manner. We further demonstrated that the Arabidopsis disease resistance locus, RPM1, conditioning resistance to avrRpm1, also conditions resistance to bacterial strains carrying avrPpiA1. Therefore, bean, pea, and conceivably other crop species contain functional and potentially molecular homologs of RPM1.

The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description.

The history, rationale, and development of the Structured Clinical Interview for DSM-III-R (SCID) is described. The SCID is a semistructured interview for making the major Axis I DSM-III-R diagnoses. It is administered by a clinician and includes an introductory overview followed by nine modules, seven of which represent the major axis I diagnostic classes. Because of its modular construction, it can be adapted for use in studies in which particular diagnoses are not of interest. Using a decision tree approach, the SCID guides the clinician in testing diagnostic hypotheses as the interview is conducted. The output of the SCID is a record of the presence or absence of each of the disorders being considered, for current episode (past month) and for lifetime occurrence.

The Structured Clinical Interview for DSM-III-R (SCID). II. Multisite test-retest reliability.

A test-retest reliability study of the Structured Clinical Interview for DSM-III-R was conducted on 592 subjects in four patient and two nonpatient sites in this country as well as one patient site in Germany. For most of the major categories, kappa s for current and lifetime diagnoses in the patient samples were above .60, with an overall weighted kappa of .61 for current and .68 for lifetime diagnoses. For the nonpatients, however, agreement was considerably lower, with a mean kappa of .37 for current and .51 for lifetime diagnoses. These values for the patient and nonpatient samples are roughly comparable to those obtained with other structured diagnostic instruments. Sources of diagnostic disagreement, such as inadequate training of interviewers, information variance, and low base rates for many disorders, are discussed.

International reliability of a diagnostic intake procedure for panic disorder.

Test-retest diagnostic reliability interviews using the Upjohn version of the Structured Clinical Interview for DSM-III (SCID) were conducted with 72 patients at 13 international sites of the Cross-National Collaborative Panic Study. Agreement on the diagnosis of panic disorder was very good. For the subtypes (uncomplicated, with limited phobic avoidance, and agoraphobia), agreement was fair to good.

The relationship of social phobia subtypes and avoidant personality disorder.

The diagnoses of social phobia (SP) and avoidant personality disorder (APD) have evolved from different historical sources, but their criteria appear to converge in DSM-III-R. Fifty anxiety disorder clinic patients with DSM-III-R SP were evaluated for presence of DSM-III-R APD. APD was present in 89% of those with the generalized subtype of SP (GSP) and 21% of those with the discrete subtype of SP (DSP). The findings are discussed in conjunction with other recent reports showing substantial overlap between GSP and APD.

Identifying common errors in the use of DSM-III through diagnostic supervision.

The authors describe the use of diagnostic supervision to identify common errors made by trainees in the application of DSM-III to multiaxial evaluations in an outpatient clinic. Errors on all five axes were due primarily to misapplications of diagnostic criteria and conventions. Errors on axes I, IV, and V were most frequent. Axis I errors were commonly due to confusion about the relationship of dysthymic disorder to major depression, neglect of substance use disorder diagnoses, and misuse of the adjustment disorder and V-code categories. On axis IV, the severity of psychosocial stressors was frequently overrated, based on several misconceptions. Axis V ratings were often erroneously overestimated because they were individualized rather than made on a uniform scale. No differences were found in the error rates of psychiatric residents compared with psychology interns except on axis I, where interns made more errors. The authors discuss the implications of these errors for training residents and psychology interns in the use of DSM-III.

Supervising intake diagnosis. A psychiatric 'Rashomon'.

Psychiatric diagnoses based on data collected during routine clinical intake evaluations done by trainees are often later used in research studies and in program evaluation. It is commonly assumed that the supervisory process can effectively overcome errors that trainees make in diagnosis. We designed a study to assess the adequacy of patient-in-absentia supervision for ensuring accurate psychiatric diagnoses. In 30% of the cases there were major diagnostic disagreements between the supervised diagnoses and consensus diagnoses based on information provided by both the trainee and an experienced clinician who sat in on the trainee's initial interview. These findings have implications for clinical care, training, and research.

Mastering the art of research interviewing. A model training procedure for diagnostic evaluation.

A training program for researchers using standard clinical assessment procedures has been developed to enhance comparability of findings across studies through reducing critical sources of unreliability. The need for such a program is especially important in large multifacility collaborative studies in which the pooling of diagnostic and rating-scale data is planned. The program described here focuses on the Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria, two instruments widely used in clinical research. It consists of the following four phases of training: use of written case vignettes, videotaped interviews, in-person training interviews, and ongoing monitoring to maintain reliability. Checks on reliability are built into each successive phase of training. This program can serve as a model for training in the use of other standard interview assessment procedures requiring clinical judgment.

Brief hospitalization: two-year follow-up.

This article presents the long-term follow-up effects of brief vs standard hospitalization on families. One hundred seventy-five newly admitted inpatients who lived with their families were randomly assigned to standard inpatient care, brief hospitalization followed by the availability of transitional day care, and brief hospitalization. All patients were offered follow-up outpatient treatment. Initial length of stay was 11 days for both brief hospitalization groups and 60 days for the standard group. The long-term results generally indicate little differential effect between treatments. When differences occurred, they generally favored the brief groups. For example, at one year the standard group families were judged to have a higher overall level of burden than the brief-day families. The findings suggest that patients are more likely to be rehospitalized because of their psychopathology than because of family burden.