The effectiveness of training and support for carers and other professionals on the physical and emotional health and well-being of looked-after children and young people: a systematic review.

Looked-after children and young people (LACYP) are recognized as a high-risk group for behavioural and emotional problems, and additional specialist training for foster carers may reduce such problems. This systematic review aimed to identify and synthesize evidence on the effectiveness of additional training and support provided to approved carers, professionals and volunteers on the physical and emotional health and well-being of LACYP (including problem behaviours and placement stability). Searches of health and social science databases were conducted and records were screened for inclusion criteria. Citation and reference list searches were conducted on included studies. Included studies were synthesized and critically appraised. Six studies were included (five randomized controlled trials and one prospective cohort study), all of which focused on foster carers. Three studies reported a benefit of training and three reported no benefit but no detriment. Those reporting a benefit of training were conducted in the USA, and had longer-duration training, shorter follow-up assessment and recruited carers of younger children than studies that reported no benefit of training, which were conducted in the UK. Whether the difference in results is due to the type of training or to cultural or population differences is unclear. The findings suggest a mixed effect of training for foster carers on problem behaviours of LACYP. The evidence identified appears to suggest that longer-duration training programmes have a beneficial effect on the behaviour problems of LACYP, although future research should examine the impact of training durations and intensity on short-medium and longer-term outcomes of LACYP of different ages. Only training and support for foster carers was identified.

Supporting the transition of looked-after young people to independent living: a systematic review of interventions and adult outcomes.

This systematic review aimed to synthesize evidence on the effectiveness of transition support services (TSSs) that are delivered towards the end of care for looked-after young people (LAYP) on their adult outcomes, including education, employment, substance misuse, criminal and offending behaviour, parenthood, housing and homelessness and health. Searches of health, social science and social care bibliographic databases were conducted and records were screened for relevance. Citation and reference list searches were conducted on included studies. Relevant studies were synthesized and critically appraised. Seven studies were identified (five retrospective and two prospective cohort studies), six of which were conducted in the USA and one in the UK. Overall, LAYP who received TSSs were more likely to complete compulsory education with formal qualifications, be in current employment, be living independently and less likely to be young parents. There was no reported effect of the impact of TSSs on crime or mental health, and mixed findings for homelessness. The range of TSS components investigated and reported varied considerably within and between studies, with limited evidence of long-term outcomes. The literature reviewed offers no reliable conclusions on the effectiveness of TSSs at this time due to variations in research quality and because few formal evaluations of existing TSSs have been conducted, resulting in mixed evidence in terms of positive, negative and neutral impact on outcomes. Further high-quality, robust research to evaluate the effectiveness of TSSs on adult outcomes for young people in the short, medium and longer term is needed to address the health inequalities experienced by this small but vulnerable group and to inform decision making about service provision.

Factors associated with outcomes for looked-after children and young people: a correlates review of the literature.

In 2008, the Department of Health made a referral to the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence to develop joint public health guidance on improving the physical and emotional health and well-being of children and young people looked after by the local authority/state. To help inform the decision-making process by identifying potential research questions pertinent to the outcomes of looked-after children and young people (LACYP), a correlates review was undertaken. Iterative searches of health and social science databases were undertaken; searches of reference lists and citation searches were conducted and all included studies were critically appraised. The correlates review is a mapping review conducted using systematic and transparent methodology. Interventions and factors that are associated (or correlated) with outcomes for LACYP were identified and presented as conceptual maps. This review maps the breadth (rather than depth) of the evidence and represents an attempt to use the existing evidence base to map associations between potential risk factors, protective factors, interventions and outcomes for LACYP. Ninety-two studies were included: four systematic reviews, five non-systematic reviews, eight randomized controlled trials, 66 cohort studies and nine cross-sectional studies. The conceptual maps provide an overview of the key relationships addressed in the current literature, in particular, placement stability and emotional and behavioural factors in mediating outcomes. From the maps, there appear to be some key factors that are associated with a range of outcomes, in particular, number of placements, behavioural problems and age at first placement. Placement stability seems to be a key mediator of directional associations. The correlates review identified key areas where sufficient evidence to conduct a systematic review might exist. These were: transition support, training and support for carers and access to services.

Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders.

Most primary care physicians do not feel competent to treat alcohol- and drug-related disorders. Physicians generally do not like to work with patients with these disorders and do not find treating them rewarding. Despite large numbers of such patients, the diagnosis and treatment of alcohol- and drug-related disorders are generally considered peripheral to or outside medical matters and ultimately outside medical education. There is substantial evidence that physicians fail even to identify a large percentage of patients with these disorders. Essential role models are lacking for future physicians to develop the attitudes and training they need to adequately approach addiction as a treatable medical illness. Faculty development programs in addictive disorders are needed to overcome the stigma, poor attitudes, and deficient skills among physicians who provide education and leadership for medical students and residents. The lack of parity with other medical disorders gives reimbursement and education for addiction disorders low priority. Medical students and physicians can also be consumers and patients with addiction problems. Their attitudes and abilities to learn about alcohol- and drug-related disorders are impaired without interventions. Curricula lack sufficient instruction and experiences in addiction medicine throughout all years of medical education. Programs that have successfully changed students' attitudes and skills for treatment of addicted patients continue to be exceptional and limited in focus rather than the general practice in U.S. medical schools. The authors review the findings of the literature on these problems, discuss the barriers to educational reform, and propose recommendations for developing an effective medical school curriculum about alcohol- and drug-related disorders.

The role of the physician in addiction prevention and treatment.

With increasing pressure on general physicians by managed care organizations and the public to treat and advocate for drug and alcohol addicted patients, it is more necessary than ever that physicians have the knowledge and skills to appropriately address this segment of the population. Specifically, physicians need a better understanding of the prevalence of alcohol and drug dependence in a variety of populations, along with increased awareness of the economic impact of addictive illnesses on our society. Routine screening questions should be incorporated into patient encounters, and physicians should be able to identify environments that may pose a risk for the development of addiction. Physicians need training and practice in referring patients to treatment teams, monitoring patients in recovery, and providing interventions that will eliminate or reduce substance abuse before it becomes addiction. The treatment outcomes in abstinence-based programs, particularly those combined with referral to AA, have been encouraging, demonstrating that addiction is a treatable illness and not a character defect. In addition, several studies provide evidence that addiction treatment is cost-beneficial, resulting in reduced medical costs, lowered absenteeism, and increased productivity. Despite these encouraging results, there is still room for improvement. Treatment is not always effective, and it is not sufficiently available to everyone who needs it. Addicted individuals are both stigmatized and marginalized, and many are too ill to advocate for themselves. Widespread recognition in the medical community of addiction as a treatable illness will contribute to a greater understanding of addictive disorders and reduce the stigma attached to the diagnosis and treatment of addiction. For this to occur, better training for physicians in the recognition and management of addictive disorders, starting at the medical school level, is necessary. The approval of addiction medicine as a clinical specialty by the American Medical Association also has helped to advance the legitimacy of addiction as a treatable illness, and provides a focal point for the synthesis and integration of clinical, teaching, and research activities central to addiction medicine. The combination of knowledge, skills, and attitudes outlined in the article will go a long way toward increasing physicians' abilities to assist their patients with recovery from addiction.

Head and neck neoplasms: magnetization transfer analysis.

PURPOSE: Magnetization transfer (MT) imaging enables analysis of the contribution of restricted motion protons in the macromolecular pool to magnetic resonance (MR) signal intensity. The authors undertook this study to determine whether MT ratios (MTRs) could be used to predict pathologic characteristics of head and neck neoplasms. MATERIALS AND METHODS: Fifty-four patients with pathologically proved neoplasms (squamous cell carcinomas, n = 33; non-squamous cell carcinomas, n = 11; benign masses, n = 10) underwent MT imaging. MTRs were correlated with pathologic findings. RESULTS: No statistically significant correlations were noted between MTRs and degree of differentiation, keratinization, cells per high-power field, and rate of mitosis. Statistically significant differences were found between MTRs of malignancies and muscle (P < .01), cerebrospinal fluid (P < .001), fat (P < .001), and benign neoplasms (P < .001). MTRs of muscle were higher than those of benign, squamous cell, and non-squamous cell neoplasms. CONCLUSION: MT imaging shows promise in differentiation of benign from malignant head and neck neoplasms. No statistically significant differences in MTRs were noted among malignancies.

Effect of steroids or tissue precooling on edema and tissue thermal coagulation after CO2 laser impact.

The carbon dioxide laser is frequently used in laryngeal microsurgery. Some surgeons have empirically used preoperative steroids or precooling with ice prior to laser impact to limit the resultant tissue thermal coagulation and/or edema. An animal model was designed to quantitatively test these effects. Depillated areas of rat skin were exposed to a CO2 beam of 1 mm diameter at 15 W for 0.1 sec after either administration of Decadron (0.25 mg/kg) immediately prior to impact or precooling more than 10 degrees C below basal body temperature. Measurement of edema was quantitated as extravasation of Evans's blue dye that had been injected intravenously. Tissue thermal coagulation was measured on hematoxylin and eosin stained histologic sections. In comparison to controls, statistically significant reduction in edema was seen only at the 24 hour time period after laser exposure for the steroid group (P less than .002) but not for the precooling group. Tissue thermal coagulation was significantly smaller for both the steroid and the ice group (P less than .006 and P less than .001, respectively) when compared to controls.

Hemangiomas of the nasal septum and paranasal sinuses.

Hemangiomas of the nasal septum and paranasal sinuses are rare; only 62 cases of septal hemangiomas and 32 cases of maxillary sinus/maxilla hemangiomas have been reported in the English literature. Hemangiomas should be considered in the differential diagnosis of any nasal mass lesion because biopsy may result in profuse bleeding and even death. We report the clinical presentation, differential diagnosis, etiology, and histologic appearance of paranasal sinus hemangiomas occurring in four of our patients.