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1.
ObjectiveTo compare the effectiveness of different screening policies for the antenatal detection of Down''s syndrome.DesignRetrospective six year survey.SettingMaternity units of eight districts.ParticipantsWomen who completed their pregnancies between 1 January 1994 and 31 December 1999 (155 501 deliveries).Results335 cases of Down''s syndrome were identified, 323 in continuing pregnancies or liveborn children. Of these, 171 were identified antenatally. Seven different screening policies were used, in three principal groups: serum screening offered to all mothers, maternal age with serum screening or nuchal translucency available to limited groups, and maternal age combined with anomaly scans. The districts that used serum screening detected 57%, those using maternal age plus serum or nuchal translucency screening 52%, and those using a maternal age of ⩾35 and anomaly scans detected 54%. The least successful district, which offered amniocentesis only to women aged over 37 years, detected only 31%. If amniocentesis had been offered from 35 years, as in all other districts, the detection rate would have risen to 54%. Across the region 15% (range 12-20%) of pregnant women were 35 years or more at delivery, and 58% (33-69%) of infants with Down''s syndrome were born to women in this age range.ConclusionsCurrent additional serum or nuchal translucency screening techniques for antenatal detection of Down''s syndrome are less advantageous than previously supposed. More pregnant women were aged over 35 than has been presumed in statistical models used in demonstration projects of serum screening and, as a result, the proportion of affected fetuses in this age group is much greater than predicted.
What is already known on this topic
Serum screening for Down''s syndrome has been presumed to be more effective than screening by maternal ageThere have been no controlled studies comparing serum screening with screening by maternal age, and its greater efficacy has been presumed from mathematical modelling, which assumed that only 5% of pregnant women were aged over 35 yearsThe modelling predicted that only 20-30% of cases of Down''s syndrome would arise in women aged over 35 and made no allowance for the effects of routine anomaly scanningWhat this study adds
15% of pregnant women were aged over 35 years, more than double the 5-7% presumed in statistical models of screening58% of babies with Down''s syndrome were born to women aged 35 years or moreSerum screening and nuchal scanning did not achieve significantly higher antenatal detection rates of Down''s syndrome than the use of maternal age and routine anomaly scanning 相似文献2.
ObjectiveTo describe parents'' experience and views of the postmortem examination after the loss of a baby.DesignCross sectional survey.SettingHospital with a dedicated bereavement counselling service, Newcastle upon Tyne.Participants258 women who had attended a bereavement counselling service at the Royal Victoria Infirmary, Newcastle upon Tyne, on at least one occasion after losing a baby during pregnancy or infancy, between October 1996 and October 2000.MethodSelf completion postal questionnaire incorporating fixed choice and open ended questions.Results166 (64%) respondents completed the questionnaire. Of these, 148 (89%) had been asked to agree to a postmortem examination on their baby and 120/148 of these respondents (81%) agreed, most of whom recognised benefits resulting from the examination. 101/117 (86%) respondents believed the findings had been explained appropriately. Nine (7%) of the 120 respondents who had agreed to a postmortem examination regretted their decision. Of the respondents who refused an examination, four (14%) had regrets about their decision.DiscussionParents viewed the postmortem examination as a useful and necessary tool in helping to discover the reasons why their baby had died. Simplifying the language used to explain findings may further raise parents'' understanding of the value of the postmortem examination and ensure that they are satisfied with it. Medical staff involved in consent for postmortem examinations should be fully trained in how to ask for parental consent, the postmortem examination procedure, and how to explain the findings.
What is already known on this topic
Current literature relates mainly to health professionals'' views of the postmortem examinationThe perceived benefits of having a postmortem examination relate mainly to improving understanding of the circumstances leading to the death of the babyWhat this study adds
Every family should be offered the opportunity for a postmortem examinationThe benefits and limitations of the postmortem examination should be explained so that expectations of the outcome are appropriateMedical concepts and terminology should be fully explained during follow up and families given the opportunity to ask questions at a later date if necessary 相似文献3.
Reto Nuesch Kerstin Schroeder Thomas Dieterle Benedict Martina Edouard Battegay 《BMJ (Clinical research ed.)》2001,323(7305):142-146
ObjectivesTo prospectively compare compliance with treatment in patients with hypertension responsive to treatment versus patients with treatment resistant hypertension.DesignProspective case-control study.SettingOutpatient department in a large city hospital in Switzerland, providing primary, secondary, and tertiary care.Participants110 consecutive medical outpatients with hypertension and taking stable treatment with at least two antihypertensive drugs for at least four weeks.ResultsComplete data were available for 103 patients, of whom 86 took ⩾80% of their prescribed doses (“compliant”) and 17 took <80% (“non-compliant”). Of the 49 patients with treatment resistant hypertension, 40 (82%) were compliant, while 46 (85%) of the 54 patients responsive to treatment were compliant.ConclusionNon-compliance with treatment was not more prevalent in patients with treatment resistant hypertension than in treatment responsive patients.
What is already known on this topic
For many patients with arterial hypertension, blood pressure cannot be adequately controlled despite treatment with antihypertensive drugsPatients'' poor compliance with treatment is often suggested as the reason for lack of response to antihypertensive drugsWhat this study adds
When treatment compliance was monitored in hypertensive patients following stable treatment regimens, no difference in compliance was found between those with treatment resistant hypertension and those responsive to treatmentFactors other than patients'' compliance with treatment regimens should be examined to explain lack of response to antihypertensive drugs 相似文献4.
David Field Elizabeth S Draper Melanie J Gompels Colin Green Ann Johnson David Shortland Mitch Blair Bradley Manktelow Caroline R Lamming Catherine Law 《BMJ (Clinical research ed.)》2001,323(7324):1276
ObjectiveTo test two methods of providing low cost information on the later health status of survivors of neonatal intensive care.DesignCluster randomised comparison.SettingNine hospitals distributed across two UK health regions. Each hospital was randomised to use one of two methods of follow up.ParticipantsAll infants born ⩽32 weeks'' gestation during 1997 in the study hospitals.MethodFamilies were recruited at the time of discharge. In one method of follow up families were asked to complete a questionnaire about their child''s health at the age of 2 years (corrected for gestation). In the other method the children''s progress was followed by clerks in the local community child health department by using sources of routine information.Results236 infants were recruited to each method of follow up. Questionnaires were returned by 214 parents (91%; 95% confidence interval 84% to 97%) and 223 clerks (95%; 86% to 100%). Completed questionnaires were returned by 201 parents (85%; 76% to 94%) and 158 clerks (67%; 43% to 91%). Most parents found the forms easy to complete, but some had trouble understanding the concept of “corrected age” and hence when to return the form. Community clerks often had to rely on information that was out of date and difficult to interpret.ConclusionNeither questionnaires from parents nor routinely collected health data are adequate methods of providing complete follow up data on children who were born preterm and required neonatal intensive care, though both methods show potential.
What is already known on this topic
Outcome of neonatal intensive care should include later health status not just early mortalityAlthough these data are commonly sought, for various reasons no existing routine system currently delivers the information for ⩾95% of the population (95% representing the minimum acceptable standard)Running one-off studies to gain later follow up data is difficult and costlyWhat this study adds
Potentially these data could come from parents but to reach 95% ascertainment perhaps 5-10% of parents would require help and support to provide informationExisting data flows may be able to provide the required information if the timing of routine reviews and methods of data recording were harmonised across the United KingdomThe costs attached to introducing such a system seem to be low 相似文献5.
Katie Palmer Lars B?ckman Bengt Winblad Laura Fratiglioni 《BMJ (Clinical research ed.)》2003,326(7383):245
ObjectivesTo evaluate a simple three step procedure to identify people in the general population who are in the preclinical phase of Alzheimer''s disease and dementia.DesignThree year population based cohort study.SettingKungsholmen cohort, Stockholm, Sweden.Participants1435 people aged 75-95 years without dementia.AssessmentsSingle question asking about memory complaints, assessment by mini-mental state examination, and neuropsychological testing.ResultsNone of the three instruments was sufficiently predictive of Alzheimer''s disease and dementia when administered separately. After participants had been screened for memory complaints and global cognitive impairment, specific tests of word recall and verbal fluency had positive predictive values for dementia of 85-100% (95% confidence intervals range from 62% to 100%). However, only 18% of future dementia cases were identified in the preclinical phase by this three step procedure. Memory complaints were the most sensitive indicator of Alzheimer''s disease and dementia in the whole population, but only half the future dementia cases reported memory problems three years before diagnosis.ConclusionThis three step procedure, which simulates what might occur in clinical practice, has a high positive predictive value for dementia, although only a small number of future cases can be identified.
What is already known on this topic
Alzheimer''s disease is characterised by a preclinical phase, during which cognitive deficits are seen before diagnosisElderly people with subjective memory complaints and objective global cognitive impairment have a high risk of developing Alzheimer''s disease and dementiaWhat this study adds
This three step procedure (self report of memory complaints, test of global cognitive functioning, and then domain specific cognitive tests) has a positive predictivity of 85-100% for Alzheimer''s disease and dementia at three yearsHowever, only 18% of people in the preclinical phase can be identified using this procedureAbout half of the people in the preclinical phase of Alzheimer''s disease and dementia do not report problems with their memory three years before diagnosis 相似文献6.
Pamela Warner Hilary O D Critchley Mary Ann Lumsden Mary Campbell-Brown Anne Douglas Gordon Murray 《BMJ (Clinical research ed.)》2001,323(7303):24-28
ObjectivesTo describe the menstrual experience of women referred for menstrual problems, in particular menorrhagia (excessive menstrual loss), and to assess associations with reasons for referral given by their general practitioners, the women''s understanding of the reasons for their attendance at the hospital clinics, and clinic outcome.DesignQuestionnaire survey, with partial review of case notes after 8 months.SettingThree hospital gynaecology clinics in Glasgow and Edinburgh.Participants952 women completed the questionnaire, and the first 665 were reviewed.ResultsOnly 38% (95% confidence interval 34% to 41%) of women reported excessive menstrual loss as a severe problem. However 60% (57-63%) gave it as reason for attending a clinic, and 76% (73-79%) of general practitioners gave it as reason for referral. Reason for referral was significantly biased towards bleeding (McNemar odds ratio 4.01, 3.0 to 5.3, P<0.001) and against pain (0.54, 0.4 to 0.7, P<0.001). Dysfunctional uterine bleeding was diagnosed in 37% (31-42%) of the 259 women who gave as reason for attendance something other than bleeding. Women who were economically disadvantaged differed in prevalence of the main diagnoses and were more likely to fail to reattend. Hysterectomy was associated with referral for bleeding (relative risk 4.9, 1.6 to 15.6, P<0.001) but not with the patient stating bleeding as the reason for clinic attendance.ConclusionsIntolerance of the volume of their bleeding is not a key feature among women attending clinics for bleeding problems. Broad menstrual complaint tends to be reframed as excessive bleeding at referral and during management. This may result in women receiving inappropriate care. Conceptualisation and assessment of menorrhagia requires reconsideration.
What is already known on this topic
Excessive menstrual loss (menorrhagia) is one of the commonest reasons for secondary referral of women, but there is no formalised clinical assessment in routine useManagement typically involves potent drugs or invasive surgery, with 60% of women having hysterectomy within 5 yearsMany women referred for menorrhagia have menstrual blood loss that is not excessiveWhat this study adds
Discordance exists between symptoms and both referral and diagnostic pathways, arising from a disproportionate focus on menstrual bleedingAmong women referred for menorrhagia, volume of bleeding is not a key symptomThis raises concerns about conceptualisation and assessment of menstrual complaint and the appropriateness of healthcare provision 相似文献7.
Johann Steurer Joachim E Fischer Lucas M Bachmann Michael Koller Gerben ter Riet 《BMJ (Clinical research ed.)》2002,324(7341):824-826
ObjectiveTo assess the extent to which different forms of summarising diagnostic test information influence general practitioners'' ability to estimate disease probabilities.DesignControlled questionnaire study.SettingThree Swiss conferences in continuous medical education.Participants263 general practitioners.InterventionQuestionnaire with multiple choice questions about terms of test accuracy and a clinical vignette with the results of a diagnostic test described in three different ways (test result only, test result plus test sensitivity and specificity, test result plus the positive likelihood ratio presented in plain language).ResultsThe correct definitions for sensitivity and predictive value were chosen by 76% and 61% of the doctors respectively, but only 22% chose the correct answer for the post-test probability of a positive screening test. In the clinical vignette doctors given the test result only overestimated its diagnostic value (median attributed likelihood ratio (aLR)=9.0, against 2.54 reported in the literature). Providing the scan''s sensitivity and specificity reduced the overestimation (median aLR=6.0) but to a lesser extent than simple wording of the likelihood ratio (median aLR=3.0).ConclusionMost general practitioners recognised the correct definitions for sensitivity and positive predictive value but did not apply them correctly. Conveying test accuracy information in simple, non-technical language improved their ability to estimate disease probabilities accurately.
What is already known on this topic
Many doctors confuse the sensitivity of clinical tests and their positive predictive valueDoctors tend to overestimate information derived from such tests and underestimate information from a patient''s clinical historyMost primary research on diagnostic accuracy is reported using sensitivity and specificity or likelihood ratiosWhat this study adds
In a cohort of experienced Swiss general practitioners most were unable to interpret correctly numerical information on the diagnostic accuracy of a screening testWhen presented with a positive result alone they grossly overestimated its valueAdding information on the test''s sensitivity and specificity moderated these overestimates, and expressing the same numerical information as a positive likelihood ratio in simple, non-technical language brought the estimates still closer to their true values 相似文献8.
ObjectivesTo describe the health and developmental status of children living in refuges for women victims of domestic violence and to investigate their access to primary healthcare services.DesignCross sectional survey.SettingWomen''s refuges in Cardiff.Participants148 resident children aged under 16 years and their mothers.Results148/257 (58%) children living in refuges between April 1999 and January 2000 were assessed. Child health system data were incorrect (general practitioner and/or address) or unavailable for 85/148 (57%) children. Uptake of all assessments and immunisations was low. 13/68 (19%) children aged <5 years had delayed or questionable development on the Denver test, and 49/101 (49%) children aged 3-15 years had a Rutter score of >10 (indicating probable mental health problems). Concerns were expressed by mothers of 113/148 (76%) children. After leaving the refuge, 22 children were untraceable and 36 returned home to the perpetrator from whom the families had fled.ConclusionsThe children had a high level of need, as well as poor access to services. Time spent in a refuge provides a window of opportunity to review health and developmental status. Specialist health visitors could facilitate and provide support, liaison, and follow up.
What is already known on this topic
A pilot study showed poor uptake of immunisations and surveillance among children who live in refuges for women victims of domestic violenceQualitative studies suggest that these children are at risk of psychological ill healthWhat this study adds
Baseline health and demographic data show that children in refuges have a high level of unmet health need, particularly in relation to mental health difficultiesTheir families have poor access to health services 相似文献9.
R C Davis F D R Hobbs J E Kenkre A K Roalfe R Hare R J Lancashire M K Davies 《BMJ (Clinical research ed.)》2002,325(7373):1156
ObjectivesTo determine the prevalence of left ventricular systolic dysfunction, and of heart failure due to different causes, in patients with risk factors for these conditions.DesignEpidemiological study, including detailed clinical assessment, electrocardiography, and echocardiography.Setting16 English general practices, representative for socioeconomic status and practice type.Participants1062 patients (66% response rate) with previous myocardial infarction, angina, hypertension, or diabetes.ResultsDefinite systolic dysfunction (ejection fraction <40%) was found in 54/244 (22.1%, 95% confidence interval 17.1% to 27.9%) patients with previous myocardial infarction, 26/321 (8.1%, 5.4% to 11.6%) with angina, 7/388 (1.8%, 0.7% to 3.7%) with hypertension, and 12/208 (5.8%, 3.0% to 9.9%) with diabetes. In each group, approximately half of these patients had symptoms of dyspnoea, and therefore had heart failure. Overall rates of heart failure, defined as symptoms of dyspnoea plus objective evidence of cardiac dysfunction (systolic dysfunction, atrial fibrillation, or clinically significant valve disease) were 16.0% (11.6% to 21.2%) in patients with previous myocardial infarction, 8.4% (5.6% to 12.0%) in those with angina, 2.8% (1.4% to 5.0%) in those with hypertension, and 7.7% (4.5% to 12.2%) in those with diabetes.ConclusionMany people with ischaemic heart disease or diabetes have systolic dysfunction or heart failure. The data support the need for trials of targeted echocardiographic screening, in view of the major benefits of modern treatment. In contrast, patients with uncomplicated hypertension have similar rates to the general population.
What is already known on this topic
The prognosis and symptoms of patients with left ventricular systolic dysfunction and heart failure can be greatly improved by modern treatmentsMany patients with heart failure do not have an assessment of left ventricular function, resulting in undertreatment of the conditionWhat this study adds
Patients with a history of ischaemic heart disease (especially those with previous myocardial infarction) or diabetes commonly have left ventricular systolic dysfunctionThese patients would be candidates for a targeted echocardiographic screening programmeIn contrast, the yield from screening patients with uncomplicated hypertension would be low 相似文献10.
ObjectivesTo examine whether self reported health status and use of health services varies in children of different social class and ethnic group.DesignCross sectional study from the 1999 health survey for England.Subjects6648 children and young adults aged 2-20 years.SettingPrivate households in England.ResultsLarge socioeconomic differences were observed between ethnic subgroups; a higher proportion of Afro-Caribbean, Indian, Pakistani, and Bangladeshi children belonged to lower social classes than the general population. The proportion of children and young adults reporting acute illnesses in the preceding two weeks was lower in Bangladeshi and Chinese subgroups (odds ratio 0.41, 95% confidence interval 0.27 to 0.61 and 0.46, 0.28 to 0.77, respectively) than in the general population. Longstanding illnesses was less common in Bangladeshi and Pakistani children (0.52, 0.40 to 0.67 and 0.57, 0.46 to 0.70) than in the general population. Irish and Afro-Caribbean children reported the highest prevalence of asthma (19.5% and 17.7%) and Bangladeshi children the lowest (8.2%). A higher proportion of Afro-Caribbean children reported major injuiries than the general population (11.0% v 10.0%), and children from all Asian subgroups reported fewer major and minor injuries than the general population. Indian and Pakistani children were more likely to have consulted their general practitioner in the preceding fortnight than the general population (1.86, 1.35 to 2.57 and 1.51, 1.13 to 2.01, respectively). Indian, Pakistani, Bangladeshi, and Chinese children were less likely to have attended outpatient departments in the preceding three months. No significant differences were found between ethnic groups in the admission of inpatients to hospitals. Acute and chronic illness were the best predictors of children''s use of health services. Social classes did not differ in self reported prevalence of treated infections, major injuries, or minor injuries, and no socioeconomic differences were seen in the use of primary and secondary healthcare services.ConclusionsChildren''s use of health services reflected health status rather than ethnic group or socioeconomic status, implying that equity of access has been partly achieved, although reasons why children from ethnic minority groups are able to access primary care but receive less secondary care need to be investigated.
What is already known on this topic
Children from lower socioeconomic classes and from Indian ethnic subgroups may make more use of general practitioners'' services than other childrenAfro-Caribbean, Indian, Pakistani, and Bangladeshi children are less likely to be referred to outpatient and inpatient services at hospitals than white childrenWhat this study adds
Indian, Pakistani, and Bangladeshi children reported less acute and chronic illness, asthma, and injuries than the general population, whereas Afro-Caribbean children reported moreChildren''s self reported health status and use of health services did not vary by social classIndian and Pakistani children make more use of general practitioners'' services, but Indian, Pakistani, Bangladeshi, and Chinese children are less likely to be referred to outpatient clinicsSelf reported health status rather than socioeconomic status or ethnicity is the best predictor of use of primary and secondary services 相似文献11.
Anne E Duggan Catherine Elliott Richard F A Logan 《BMJ (Clinical research ed.)》1999,319(7219):1236-1239
ObjectiveTo evaluate the performance of a near patient test for Helicobacter pylori infection in primary care.DesignValidation study performed within a randomised trial of four management strategies for dyspepsia.Setting43 general practices around Nottingham.Subjects394 patients aged 18-70 years presenting with recent onset dyspepsia.ResultsWhen used in primary care FlexSure test had a sensitivity and specificity of 67% (95% confidence interval 59% to 75%) and 98% (95% to 99%) compared with a sensitivity and specificity of 92% (87% to 97%) and 90% (83% to 97%) when used previously in secondary care. Of the H pylori test and refer group 14% (28/199) were found to have conditions for which H pylori eradication was appropriate compared with 23% (39/170) of the group referred directly for endoscopy.ConclusionsWhen used in primary care the sensitivity of the FlexSure test was significantly poorer than in secondary care. About a third of patients who would have benefited from H pylori eradication were not detected. Near patient tests need to be validated in primary care before they are incorporated into management policies for dyspepsia.
Key messages
- Near patient tests for H pylori infection have been recommended in the management of dyspepsia in primary care without proper evaluation
- Such tests should have a high sensitivity to avoid missing treatable illness related to infection
- The FlexSure near patient test had a lower sensitivity than previously reported in validation studies performed in secondary care
- Fewer than expected numbers of patients with H pylori related pathology were identified with the FlexSure in primary care
12.
Imran Mushtaq Stuart Logan Michael Morris Andrew W Johnson Angie M Wade Deirdre Kelly Peter T Clayton 《BMJ (Clinical research ed.)》1999,319(7208):471-477
ObjectiveTo assess the feasibility of screening for cholestatic hepatobiliary disease and extrahepatic biliary atresia by using tandem mass spectrometry to measure conjugated bile acids in dried blood spots obtained from newborn infants at 7-10 days of age for the Guthrie test.SettingThree tertiary referral clinics and regional neonatal screening laboratories.DesignUnused blood spots from the Guthrie test were retrieved for infants presenting with cholestatic hepatobiliary disease and from the two cards stored on either side of each card from an index child. Concentrations of conjugated bile acids measured by tandem mass spectrometry in the two groups were compared.Results218 children with cholestatic hepatobiliary disease were eligible for inclusion in the study. Two children without a final diagnosis and five who presented at <14 days of age were excluded. Usable blood spots were obtained from 177 index children and 708 comparison children. Mean concentrations of all four bile acid species were significantly raised in children with cholestatic hepatobiliary disease and extrahepatic biliary atresia compared with the unaffected children (P<0.0001). Of 177 children with cholestatic hepatobiliary disease, 104 (59%) had a total bile acid concentration >33 μmol/l (97.5th centile value for comparison group). Of the 61 with extrahepatic biliary atresia, 47 (77%) had total bile acid concentrations >33 μmol/l. Taurotrihydroxycholanoate and total bile acid concentrations were the best predictors of both conditions. For all cholestatic hepatobiliary disease, a cut off level of total bile acid concentration of 30 μmol/l gave a sensitivity of 62% and a specificity of 96%, while the corresponding values for extrahepatic biliary atresia were 79% and 96%.ConclusionMost children who present with extrahepatic biliary atresia and other forms of cholestatic hepatobiliary disease have significantly raised concentrations of conjugated bile acids as measured by tandem mass spectrometry at the time when samples are taken for the Guthrie test. Unfortunately the separation between the concentrations in these infants and those in the general population is not sufficient to make mass screening for cholestatic hepatobiliary disease a feasible option with this method alone.
Key messages
- The prognosis of cholestatic hepatobiliary disease in infancy, in particular biliary atresia, is improved by early detection
- Infants destined to present with cholestatic jaundice in the first few months of life have raised concentrations of bile acids in the blood spots obtained at 7-10 days for current neonatal screening programmes
- Tandem mass spectrometry can be used to detect this marker of neonatal cholestasis
- Unfortunately there is too much overlap between bile acid concentrations in infants with cholestasis and those in control infants for this to be used as a single screening test for cholestatic hepatobiliary disease in general and biliary atresia
- Tandem mass spectrometry is a powerful tool for neonatal screening but every potential application must be carefully assessed
13.
Environmental Influences on Children's Physical Activity: Quantitative Estimates Using a Twin Design
Background
Twin studies offer a ‘natural experiment’ that can estimate the magnitude of environmental and genetic effects on a target phenotype. We hypothesised that fidgetiness and enjoyment of activity would be heritable but that objectively-measured daily activity would show a strong shared environmental effect.Methodology/Principal Findings
In a sample of 9–12 year-old same-sex twin pairs (234 individuals; 57 MZ, 60 DZ pairs) we assessed three dimensions of physical activity: i) objectively-measured physical activity using accelerometry, ii) ‘fidgetiness’ using a standard psychometric scale, and iii) enjoyment of physical activity from both parent ratings and children''s self-reports. Shared environment effects explained the majority (73%) of the variance in objectively-measured total physical activity (95% confidence intervals (CI): 0.63–0.81) with a smaller unshared environmental effect (27%; CI: 0.19–0.37) and no significant genetic effect. In contrast, fidgetiness was primarily under genetic control, with additive genetic effects explaining 75% (CI: 62–84%) of the variance, as was parent''s report of children''s enjoyment of low 74% (CI: 61–82%), medium 80% (CI: 71–86%), and high impact activity (85%; CI: 78–90%), and children''s expressed activity preferences (60%, CI: 42–72%).Conclusions
Consistent with our hypothesis, the shared environment was the dominant influence on children''s day-to-day activity levels. This finding gives a strong impetus to research into the specific environmental characteristics influencing children''s activity, and supports the value of interventions focused on home or school environments. 相似文献14.
Bedford H de Louvois J Halket S Peckham C Hurley R Harvey D 《BMJ (Clinical research ed.)》2001,323(7312):533-536
ObjectiveTo describe important sequelae occurring among a cohort of children aged 5 years who had had meningitis during the first year of life and who had been identified by a prospective national study of meningitis in infancy in England and Wales between 1985 and 1987.DesignFollow up questionnaires asking about the children''s health and development were sent to general practitioners and parents of the children and to parents of matched controls. The organism that caused the infection and age at infection were also recorded.SettingEngland and Wales.ParticipantsGeneral practitioners and parents of children who had had meningitis before the age of 1 year and of matched controls.ResultsAltogether, 1584 of 1717 (92.2%) children who had had meningitis and 1391 of 1485 (93.6%) controls were successfully followed up. Among children who survived to age 5 years 247 of 1584 (15.6%) had a disability; there was a 10-fold increase in the risk of severe or moderate disability at 5 years of age among children who had had meningitis (relative risk 10.3, 95% confidence interval 6.7 to 16.0, P<0.001). There was considerable variation in the rates of severe or moderate disability in children infected with different organisms.ConclusionThe long term consequences of having meningitis during the first year of life are significant: 32 of 1717 (1.8%) children died within five years. Not only did almost a fifth of children with meningitis have a permanent, severe or moderately severe disability, but subtle deficits were also more prevalent.
What is already known on this topic
Meningitis in infancy is associated with important long term consequencesThere is considerable variation in outcome depending on which organism caused the infectionWhat this study adds
This follow up study of 1717 children who had meningitis in infancy found that they had a 10-fold increase in risk of severe or moderate disabilities at age 5 years compared with children in the control groupThe outcome of having meningitis was associated with the age at infection, and children who had meningitis in the neonatal period were more likely to have health and development problems than those older than 1 monthSubtle deficits, such as middle ear disease and visual and behavioural problems, were more prevalent among children who had had meningitis in infancy 相似文献15.
Trinh Duong A E Ades Diana M Gibb Pat A Tookey Janet Masters 《BMJ (Clinical research ed.)》1999,319(7219):1227-1229
ObjectiveTo estimate and interpret time trends in vertical transmission rates for HIV using data from national obstetric and paediatric surveillance registers.DesignProspective study of HIV infected women reported through obstetric surveillance. HIV infection status of the child and onset of AIDS were reported through paediatric surveillance. Rates of vertical transmission and progression to AIDS rate were estimated by methods that take account of incomplete follow up of children with indeterminate infection status and delay in AIDS reporting.SettingBritish Isles.SubjectsPregnant women infected with HIV whose infection was diagnosed before delivery, and their babies.ResultsBy January 1999, 800 children born to diagnosed HIV infected women who had not breast fed had been reported. Vertical transmission rates rose to 19.6% (95% confidence interval 8.0% to 32.5%) in 1993 before falling to 2.2% (0% to 7.8%) in 1998. Between 1995 and 1998 use of antiretroviral treatment increased significantly each year, reaching 97% of live births in 1998. The rate of elective caesarean section remained constant, at around 40%, up to 1997 but increased to 62% in 1998. Caesarean section and antiretroviral treatment together were estimated to reduce risk of transmission from 31.6% (13.6% to 52.2%) to 4.2% (0.8% to 8.5%). The proportion of infected children developing AIDS in the first 6 months fell from 17.7% (6.8% to 30.8%) before 1994 to 7.2% (0% to 15.7%) after, coinciding with increased use of prophylaxis against Pneumocystis carinii pneumonia.ConclusionsIn the British Isles both HIV related morbidity and vertical transmission are being reduced through increased use of interventions.
Key messages
- Reliable estimates of HIV vertical transmission rates can be derived from surveillance data
- Infected pregnant women are increasingly taking up elective caesarean section and antiretroviral treatment to reduce the risk of transmitting HIV to their babies
- Vertical transmission rates have fallen greatly over the past four years and progression to AIDS among infected children may also have slowed
- These benefits can occur only if infected women are diagnosed before or during pregnancy
16.
Mario Cortina-Borja Hooi Kuan Tan Martine Wallon Malgorzata Paul Andrea Prusa Wilma Buffolano Gunilla Malm Alison Salt Katherine Freeman Eskild Petersen Ruth E. Gilbert for The European Multicentre Study on Congenital Toxoplasmosis 《PLoS medicine》2010,7(10)
Background
The effectiveness of prenatal treatment to prevent serious neurological sequelae (SNSD) of congenital toxoplasmosis is not known.Methods and Findings
Congenital toxoplasmosis was prospectively identified by universal prenatal or neonatal screening in 14 European centres and children were followed for a median of 4 years. We evaluated determinants of postnatal death or SNSD defined by one or more of functional neurological abnormalities, severe bilateral visual impairment, or pregnancy termination for confirmed congenital toxoplasmosis. Two-thirds of the cohort received prenatal treatment (189/293; 65%). 23/293 (8%) fetuses developed SNSD of which nine were pregnancy terminations. Prenatal treatment reduced the risk of SNSD. The odds ratio for prenatal treatment, adjusted for gestational age at maternal seroconversion, was 0.24 (95% Bayesian credible intervals 0.07–0.71). This effect was robust to most sensitivity analyses. The number of infected fetuses needed to be treated to prevent one case of SNSD was three (95% Bayesian credible intervals 2–15) after maternal seroconversion at 10 weeks, and 18 (9–75) at 30 weeks of gestation. Pyrimethamine-sulphonamide treatment did not reduce SNSD compared with spiramycin alone (adjusted odds ratio 0.78, 0.21–2.95). The proportion of live-born infants with intracranial lesions detected postnatally who developed SNSD was 31.0% (17.0%–38.1%).Conclusion
The finding that prenatal treatment reduced the risk of SNSD in infected fetuses should be interpreted with caution because of the low number of SNSD cases and uncertainty about the timing of maternal seroconversion. As these are observational data, policy decisions about screening require further evidence from a randomized trial of prenatal screening and from cost-effectiveness analyses that take into account the incidence and prevalence of maternal infection. Please see later in the article for the Editors'' Summary 相似文献17.
Frank H. Guenther Jonathan S. Brumberg E. Joseph Wright Alfonso Nieto-Castanon Jason A. Tourville Mikhail Panko Robert Law Steven A. Siebert Jess L. Bartels Dinal S. Andreasen Princewill Ehirim Hui Mao Philip R. Kennedy 《PloS one》2009,4(12)
Background
Brain-machine interfaces (BMIs) involving electrodes implanted into the human cerebral cortex have recently been developed in an attempt to restore function to profoundly paralyzed individuals. Current BMIs for restoring communication can provide important capabilities via a typing process, but unfortunately they are only capable of slow communication rates. In the current study we use a novel approach to speech restoration in which we decode continuous auditory parameters for a real-time speech synthesizer from neuronal activity in motor cortex during attempted speech.Methodology/Principal Findings
Neural signals recorded by a Neurotrophic Electrode implanted in a speech-related region of the left precentral gyrus of a human volunteer suffering from locked-in syndrome, characterized by near-total paralysis with spared cognition, were transmitted wirelessly across the scalp and used to drive a speech synthesizer. A Kalman filter-based decoder translated the neural signals generated during attempted speech into continuous parameters for controlling a synthesizer that provided immediate (within 50 ms) auditory feedback of the decoded sound. Accuracy of the volunteer''s vowel productions with the synthesizer improved quickly with practice, with a 25% improvement in average hit rate (from 45% to 70%) and 46% decrease in average endpoint error from the first to the last block of a three-vowel task.Conclusions/Significance
Our results support the feasibility of neural prostheses that may have the potential to provide near-conversational synthetic speech output for individuals with severely impaired speech motor control. They also provide an initial glimpse into the functional properties of neurons in speech motor cortical areas. 相似文献18.
ObjectiveTo determine the efficacy, gastrointestinal safety, and tolerability of celecoxib (a cyclo-oxygenase 2 (COX 2) inhibitor) used in the treatment of osteoarthritis and rheumatoid arthritis.DesignSystematic review of randomised trials that compared at least 12 weeks'' celecoxib treatment with another non-steroidal anti-inflammatory drug (NSAID) or placebo and reported efficacy, tolerability, or safety. Trials identified from manufacturer and by searching electronic databases and evaluated according to predefined inclusion and quality criteria. Data combined through meta-analysis.Participants15 187 patients with osteoarthritis or rheumatoid arthritis.ResultsNine randomised controlled trials were included. Celecoxib and NSAIDS were equally effective for all efficacy outcomes. Compared with those taking other NSAIDs, in patients taking celecoxib the rate of withdrawals due to adverse gastrointestinal events was 46% lower (95% confidence interval 29% to 58%; NNT 35 at three months), the incidence of ulcers detectable by endoscopy was 71% lower (59% to 79%; NNT 6 at three months), and the incidence of symptoms of ulcers, perforations, bleeds, and obstructions was 39% lower (4% to 61%; NNT 208 at six months). Subgroup analysis of patients taking aspirin showed that the incidence of ulcers detected by endoscopy was reduced by 51% (14% to 72%) in those given celecoxib compared with other NSAIDs. The reduction was greater (73%, 52% to 84%) in those not taking aspirin.ConclusionCelecoxib is as effective as other NSAIDs for relief of symptoms of osteoarthritis and rheumatoid arthritis and has significantly improved gastrointestinal safety and tolerability.
What is already known on this topic
Long term NSAID use is associated with the development of peptic and duodenal ulcersCOX 2 specific inhibitors are claimed to cause fewer gastrointestinal complicationsThe National Institute for Clinical Excellence has recently recommended that COX 2 specific inhibitors are used in patients with arthritis who are at risk of gastrointestinal complications but not in those taking prophylactic aspirinWhat this study adds
Systematic review of randomised trials shows that celecoxib is as effective as other NSAIDs for osteoarthritis and rheumatoid arthritisCelecoxib has significantly improved gastrointestinal safety and tolerability compared with standard NSAIDsAn improvement in gastrointestinal safety was still evident in patients who were also taking aspirin 相似文献19.
Are seat belt restraints as effective in school age children as in adults? A prospective crash study
Stephen I Halman Mary Chipman Patricia C Parkin James G Wright 《BMJ (Clinical research ed.)》2002,324(7346):1123
ObjectiveTo study effectiveness of seat belts for protecting school age children in road vehicle crashes.DesignCrash examinations by trained investigators.SettingTen Canadian university based crash investigation centres.Subjects470 children aged 4-14 years, with 168 selected for detailed analysis, and 1301 adults.ResultsOverall, 40% (189/470) of children were unbelted. Of the 335 children in cars driven by belted adults, 73 (22%) were unbelted. The odds of sustaining fatal or moderately severe injury (injury severity score ⩾4) for children in the front passenger seat was more than nine times higher for unbelted children than for belted ones (odds ratio 9.8 (95% confidence interval 2.4 to 39.4)) and for those in the rear left seat was more than two times higher for unbelted than for belted children (2.6 (1.1 to 5.9)). The protection afforded by seat belts compared favourably with the results for adults in the same seat positions (odds ratios for unbelted v belted adults of 2.4 and 2.7 for front and rear seat passengers respectively).ConclusionsSeat belts helped to protect school age children from injury in road vehicle crashes. However, 40% of children were unbelted. Despite standard seat belts being designed for adults, school age children were at least as well protected as adults.
What is already known on this topic
Although child restraints protect young children in road vehicle crashes, it is not known whether standard seat belts used by school age children work as wellSchool age children are often unbelted in carsWhat this study adds
Data from detailed crash assessments indicate that seat belts protected children at least as well as adultsAdults were more likely than children to be belted, and 22% of children travelling with belted drivers were unbelted 相似文献20.