Controlled trial of psychiatric nurse therapists in primary care.

In a randomised controlled clinical trial neurotic patients (mainly phobic and obsessive-compulsive) did significantly better up to one year follow up after receiving behavioural psychotherapy from a nurse therapist rather than routine treatment from a general practitioner. At the end of the year control patients who had not improved had crossover behavioural treatment from the nurse and then improved. Those who dropped out or refused therapy did not show worthwhile gains. Patients preferred being treated in the primary care setting rather than in hospital. Placing nurse therapists in primary care is not only viable but may save more health care resources than it consumes.     

Working with Dreams in Psychotherapy: The Therapists' Perspective

129 therapists completed a 70-item questionnaire about working with dreams in psychotherapy. Almost all therapists (92%) worked with dreams in psychotherapy at least occasionally. Therapists reported that 15% of clients had brought dreams into therapy during the past year. Therapists engaged more in exploratory than insight- or action-oriented activities when working with dreams. They were more likely to work on dreams with clients who had troubling dreams or who were interested in working on dreams, but were unlikely to work on dreams with schizophrenic or psychotic clients. Those clinicians who were more likely to work with dreams had more training, higher estimated dream recall, more positive attitudes toward dreams, and did more personal dream work than clinicians who were not likely to work with dreams.     

Patients who usually consult the trainee in general practice.

An analysis of every tenth case record from each year of birth and for both sexes from a patient list in a practice with three partners showed that 13% of patients who attended the health centre at least twice a year had usually consulted a trainee. These patients were usually young adults, free from known important long term health problems, and they had closely similar clinical characteristics to those patients who did not usually consult the same principal. Few patients usually consulted each trainee over three years.     

Social effects of wheeze in childhood: a 25 year follow up.

OBJECTIVES--To determine the outcome of childhood wheeze in terms of education, employment, housing, and social class. DESIGN--25 year follow up study. SETTING--Community study based at the department of thoracic medicine, Aberdeen Royal Infirmary. PARTICIPANTS--Three groups of subjects who had been identified in a random community survey in 1964: those who had had asthma in childhood (n = 97), those who had wheezed only in the presence of upper respiratory tract infections (n = 132), and a comparison group who had had no respiratory symptoms as children (n = 131). Subjects were aged 34 to 40 years at the time of the current study. MAIN OUTCOME MEASURES--Interview and questionnaire data on education, employment, housing and social class, ventilatory function, and peak flow rate. RESULTS--Pulmonary function testing showed that only the "asthmatic" group had airways obstruction; this group showed greater peak flow variation than the "wheezy" group, which did not differ from the comparison group. The asthmatic subjects were more likely to have experienced respiratory problems during their school years and associated with their work. Despite these problems, educational attainment, employment, housing, and eventual social class were similar for all three groups. CONCLUSION--Childhood wheeze did not adversely affect education, employment, housing, or social class in this population.     

AIDS and the general practitioner: views of patients with HIV infection and AIDS.

An unselected series of outpatients infected with the human immunodeficiency virus (HIV) who attended two London hospitals were interviewed to assess their relationship with their general practitioner. Although most of the 192 patients were registered with a general practitioner, the doctors of only one half knew of the diagnosis. Patients feared a negative reaction from their general practitioner or were concerned about confidentiality. Although those who had told their doctor had received favourable reactions, few general practitioners attempted to counsel or educate their patients. The patients who previously had been open about their homosexuality were not more likely to have told their general practitioner of their HIV infection. Although most did not think that general practitioners were well informed about AIDS, half of the patients wished that general practitioners could take a bigger part in their care.     

Assessing the consultation: methods of observing trainees in general practice.

We compared two different methods of observing trainees at work in general practice: the traditional one of a senior or training general practitioner sitting in during selected surgeries and the more modern video recording, with the patients'' written consent. Patients who had experienced the presence of a second doctor during the consultation were less likely to show an increase in arousal after their consultations than those who had been recorded on video. Patients who refused consent to be recorded were more highly stressed than those who agreed and showed smaller decreases in stress after consultations. The presence of two doctors generated fewer reductions in stress after the consultation than video recording did, but this was a non-significant trend. The group that was recorded on video did not differ appreciably from a control group in changes in stress or arousal.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

Patients' attitudes to induction and labour.

An attempt was made to ascertain patients'' attitudes towards planned induction and labour. Twenty per cent of patients had not heard of induction before their pregnancy, and those who had had most probably heard about it from relations and friends rather than the media. Most patients had no firm opinions on induction of labour but were usually glad to have their pregnancy ended. Many considered that they had not been given enough information by the medical staff on their induction. The amount of pain experienced by patients at amniotomy was related to the "favourability" of the cervix. Possibly women with a low cervical score should be given more premedication or inhalation analgesia at amniotomy. Most patients found injections of narcotic agents adequate analgesia in labour. Those patients who did not receive adequate analgesia were principally those who had either very short or quite long labours. Patients with long labours may benefit from more liberal use of analgesia, but no satisfactory form of analgesia seems to be available for patients who are likely to deliver within two or three hours of induction.     

The flying buttress construct for posterior spinopelvic fixation: a technical note

Background

School screening for adolescent idiopathic scoliosis (AIS) is discussed. The aim of the present study was to describe the point prevalence of AIS and to evaluate the effectiveness of school screening in 12-year- old children.

Methods

Community nurses and physical therapists in the Southern Health region of Norway including about 12000 school children aged 12 years were invited to participate. All participating community nurses and physical therapists fulfilled an educational course to improve their knowledge about AIS and learn the screening procedure including the Adam Forward Bending Test and measurement of gibbus using a scoliometer.

Results

Sub-regions including 4000 school children participated. The prevalence of idiopathic scoliosis defined as a positive Adam Forward Bending Test, gibbus > 7° and primary major curve on radiographs > 10°, was 0.55%. Five children (0.13%) had a major curve > 20°. Bracing was not indicated in any child; all children were post menarche; four had Risser sign of 4, and one with Risser 1 did not have curve progression > 5° at later follow-up. In one of these 5 children however, the major curve progressed to 45° within 7 months after screening and the girl was operated.

Conclusion

The point prevalence of AIS in 12- year old children is in agreement or slightly lower than previous studies. The screening model employed demonstrates acceptable sensitivity and specificity and low referral rates. Screening at the age of 12 years only was not effective for detecting patients with indication for brace treatment.     

Diagnosing cancer in general practice: from suspicion to certainty.

Three hundred and eighty two patients who were suspected of having cancer by general practitioners were followed up for up to two years until the suspicion was either confirmed or rejected; 7014 patients who were not suspected of having a malignancy served as the control group. Less than every tenth suspicion proved correct. The general practitioner''s assessment of the strength of suspicion of cancer was the best predictor of outcome in the suspected patients. The incidence of cancer among the unsuspected patients did not differ from the total incidence of cancer in the study area. The patient''s fear of cancer was an important predictor of a malignancy. A higher proportion of patients who consulted for non-symptomatic reasons than for symptomatic reasons was reported to have a malignancy. No single symptom had a strong predictive value for cancer. The predictive value of a palpable lump or tumour was 2.5%.     

How much personal care in four group practices?

OBJECTIVE--To establish the degree of continuity of care in general practice. DESIGN--Retrospective study of the records of all eligible patients attending the surgery at randomly selected sessions. SETTING--Four large group practices in the Southampton Health District, one of which operated a strict system of personal lists. PATIENTS--776 Patients who had been registered for at least two years and had consulted at least 12 times over six years or less. MAIN OUTCOME MEASURES--Continuity score for each patient calculated from the number of consultations (out of the past 12) with his or her usual doctor. Number of the times the patients had consulted the doctor with whom they were registered. RESULTS--In the practice with personal lists a mean of 10 of the 12 consultations had been with the same doctor (83% of consultations), but in the three practices with combined lists the means were 5.9 (49%), 6.2 (52%), and 6.9 (58%). Continuity was associated with increased age and with the recording of a major problem. In the practices with combined lists 63 of 72 children consulted at least five different doctors. Only 140 of 489 patients currently in the practice who were identified as being registered with a doctor had most usually consulted that doctor in the practices with combined lists. CONCLUSIONS--Personal continuity of care may be fairly low in group practice, especially for younger and healthier patients registered at practices with combined lists. These findings support the Department of Health''s recent decision to make "target payments" (for cervical smears and childhood immunisations) to groups rather than to individual principals but pose a question for the future of individual clinical responsibility.     

METHYL-BIS (BETA-CHLOROETHYL) AMINE IN LARGE DOSES IN THE TREATMENT OF NEOPLASTIC DISEASES

Sixty-seven patients with neoplastic diseases were treated with 151 courses of methylbis (beta-chloroethyl)amine hydrochloride (HN₂). Seventy-seven of the courses consisted of single injections of 0.2 to 0.4 mg. per kilogram of body weight, and 35 courses were given as single injections of 0.6 mg. per kilogram of body weight.Twenty-three patients with Hodgkin''s disease were treated. Remissions averaged approximately three months in 13 patients who were in good or fair general physical condition, and 1.5 months in 11 patients who were in poor or moribund condition; one of the 11 did not respond to the therapy.Fifteen patients with lymphosarcoma were treated. Remissions averaged between one and two months in four patients who were in good or fair general physical condition. Of the remaining 11 patients, two showed no response, and the longest remission among the remaining nine was approximately 40 days.Satisfactory remissions of one to three months were obtained in four patients with mycosis fungoides treated with single courses of 0.3 mg. per kilogram of body weight.Serious toxic reactions were observed in six patients, four of whom died. In five of the six instances the reactions consisted of pancytopenia and hemorrhagic diathesis. All these patients were in poor general or hematologic status before therapy.In general, large single doses of HN₂ were neither more nor less effective than the four-to six-day course usually employed with this agent. Combination of the administration of HN₂ with artificial hyperpyrexia, or with concurrent courses of pteroylglutamic conjugates, did not enhance the therapeutic effects of the agent.     

Salutogenic factors that may enhance lifelong oral health in an elderly Japanese population

Objectives: The objective of this study was to assess which factors affected the maintenance of more than 20 teeth in Japanese patients aged 80 years and older, using a life‐course perspective. Subjects and methods: The oral examination was carried out by dentists. The questionnaire asked about family background, background during various stages of growing up, tooth brushing, snacking, job history, health examination, war experience, number of children, oral health condition and dietary preferences. Some of the questions asked about conditions when they were a primary school student, 20 years old, 40 years old and 60 years old. Multivariable logistic‐regression analysis was used to adjust for sex at significant life stages. Results: The group with mothers who did not prefer sweet food had an approximately four times greater chance of having ≥20 teeth compared with the group with mothers who preferred sweet food. Those participants who did not prefer sweet food themselves were approximately three to five times more likely to be in the ≥20 tooth group compared with those who preferred sweet food at all stages of their life course. Non‐smokers and those who quit smoking were three times more likely to be in the ≥20 tooth group than those who smoked throughout the years from 20 to 60 years of age. Conclusions: Factors associated with the maintenance of a sufficient number of functioning teeth were: not having a mother with a preference for sweet food, not having a preference for sweet food themselves and not smoking over a long period.     

A study of contraception as related to multiple unwanted pregnancies

A group of 25 women who had had two or more therapeutic abortions was compared with a control group of 100 women who had had only one abortion. The two groups could not be distinguished on the basis of the available demographic data. Emotional problems that interfere with the proper utilization of contraceptives were apparent in the index group and 76% of patients in this group had a primary psychiatric disorder as compared with 52% in the control group. The most common psychiatric diagnosis in the index group was chronic depressive reaction. A therapeutic abortion in the index group did not prompt an increased or more effective utilization of contraceptives.     

Risk factors for acquiring Helicobacter pylori infection in a group of Tuscan teenagers

Risk factors for acquiring Helicobacter pylori infection include hygienic, social, and environmental conditions. Some of these conditions usually change over time. We therefore investigated the existence of risk factors in a group of teenagers living in a place with the same environmental characteristics, in which hygienic and crowding conditions have not changed significantly in the last 20 years. A group of 164 students, mostly borne in 1977, attending four different schools, were examined serologically for H. pylori infection and CagA status. The importance of the risk factors for the transmission of the infection were evaluated by the chi2 test. P values <0.05 were considered significant. Twenty-two students (13.4%) were H. pylori seropositive. Students attending teachers' college and high school of arts were infected significantly more often than those attending high school (P = 0.011 and P = 0.012, respectively). Students who smoked and students whose parents had a manual job had an increased risk of acquiring the infection (P = 0.002, and P = 0.036, respectively). Crowding conditions and the presence of domestic animals were close to being statistically significant. Other factors, such as gender, number of bathrooms and bedrooms, sharing the bed with adults as a child, presence of a sexual partner, and a family history of peptic ulcer and gastric cancer, did not increase the risk of infection. The prevalence of seropositivity for CagA was similar in the various risk groups. Manual job of parents and smoking were the most important factors for acquiring H. pylori infection.     

Desensitization to Methimazole

ObjectiveThionamides (methimazole and propylthiouracil) have been associated with common side effects, such as rash and pruritus, and rare but serious adverse effects, such as agranulocytosis and hepatotoxicity. Methimazole is usually the preferred thionamide for the treatment of hyperthyroidism if the patient is not planning to conceive or not in the first trimester of pregnancy, given the less frequent dosing and lower risk of hepatotoxicity. In patients who experience rash or itching when treated with methimazole, switching them to propylthiouracil is one treatment option. Here we report our experience regarding desensitization to methimazole to allow continued treatment with methimazole as an alternative management option.MethodsWe conducted a retrospective chart review of patients at a single institution who had side effects to methimazole and who were desensitized to methimazole under the supervision of an allergist. A total of 7 patients were included who experienced side effects to methimazole that did not include agranulocytosis or hepatotoxicity.ResultsAll 7 patients were able to take methimazole for treatment of their hyperthyroidism, either for continued medical therapy or as a bridge to definitive therapy, with either surgery or radioactive iodine treatment.ConclusionUnder the supervision of an allergist, desensitization to methimazole is an option for treating patients who experience side effects to methimazole (excluding agranulocytosis and hepatotoxicity).     

Long-term Prognosis following Ventricular Fibrillation in Acute Ischaemic Heart Disease

Of 160 patients who survived ventricular fibrillation complicating acute ischaemic heart disease, 80 had had a clinically mild coronary attack. Most of the long-term survivors had ventricular fibrillation within 24 hours of the onset of symptoms. The longterm prognosis of the survivors was similar to that of patients whose myocardial infarction was not complicated by ventricular fibrillation. Those patients who survived ventricular fibrillation which occurred within four hours of the onset of symptoms were younger, usually had had a mild coronary attack, and had the most favourable longterm prognosis. The number of episodes of ventricular fibrillation did not affect adversely the long-term prognosis. Of those who at the time of review were eligible to work, 86% were fit to work and 68% were actually at work.     

Factors Affecting Unhappiness at School among Japanese Adolescents: An Epidemiological Study

Background

Unhappiness at school is one of the main reasons for truancy among adolescents. In order to assess this problem more thoroughly in the context of Japanese adolescents, the present study examined the associations between feelings of unhappiness at school and lifestyle habits, school life realities, and mental health status.

Method

This study was designed as a cross-sectional survey. A self-administered questionnaire was provided to students enrolled in randomly selected junior and senior high schools throughout Japan. We calculated the percentages of both junior and senior high school students who felt unhappy at school based on factors related to school life, lifestyle habits, and mental health status. Multiple logistic regression analyses were performed in order to examine the associations between those factors and students'' feelings of unhappiness at school.

Results

A total of 98,867 valid responses were analysed, 7.9% (Boys: 8.4%, Girls: 7.4%) of which came from students who responded that they felt unhappy at school. For both junior and senior high school students, the percentages of those who felt unhappy at school were significantly higher among those who had not yet decided on their future life course, who did not participate in extracurricular activities, did not eat breakfast every day, went to bed late, had used tobacco or alcohol in the previous 30 days, and had poor mental health compared with others. The results of multiple logistic regression analyses indicated that the adjusted odds ratios for feeling unhappy at school with regard to the above-mentioned factors were significantly high for both junior and senior high school students.

Conclusions

The present results suggest that school employees and administrators must provide health guidance to students, considering that irregular lifestyle habits, lower school engagement, smoking, drinking alcohol, and poor mental health status are all associated with maladaptation to school among adolescents.     

Dream work with children: Perceptions and practices of school mental health professionals.

In this study, 49 public school mental health practitioners (school counselors, school psychologists, and school social workers) completed a survey about working with students’ dreams. The majority of these practitioners reported having at least one student bring up dreams during counseling, more frequently with troubling dreams and nightmares or when coping with grief. Results showed that practitioners were less likely to talk about dreams with students who had been identified with an adjustment disorder, psychosis, or eating disorder; those who were oppositional or ill; and those who struggled with substance abuse problems. Although most practitioners did not feel competent working with children’s dreams and reported minimal training in dream work, they were interested in learning more about children’s dreams and potential uses of dream work in supportive counseling. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Streptococcal L forms and phage. A clinical-epidemiologic study

This study showed that streptococcal L forms could not be isolated from children who were either carriers of group A streptococci or had disease due to this pathogen. It was possible to induce L colony formation in 15 strains of group A. Streptococcal bacteriophages were demonstrated in 20% of group A streptococci isolated from school children who were carriers, but did not have clinical evidence of streptococcal disease, and from 44.9% of children whose physicians considered they had acute streptococcal upper respiratory infections. Lysogeny (bacteriophage) was demonstrated more frequently during 1969-70 when carrier rates were high and from children who had manifest streptococcal disease, suggesting a possible positive relationship between lysogeny, high carrier rates, and infection in the children studied. Lysogeny and erythrogenic toxin production by group A streptococci occurred simultaneously in approximately half of the strains of group A streptococci tested, suggesting that lysogeny is not a sine qua non for erythrogenic toxin production.