James Parkinson (1755-1824): A pioneer of child care

James Parkinson (1755-1824) of Parkinson's disease, is well recognized as a pioneer of clinical neurology; and is even more famous as a founder of modem palaeontology. We have reviewed from primary sources his extensive contributions to clinical child care and his pioneering advocacy for child welfare, protection and safety. His writings, outreach and advocacy for children's health characterizes him as one whose influence was an important springboard from which evolved the modern specialty of paediatrics. Parkinson was one of the first to write on child-rearing practices and in this context antedated Benjamin Spock by 150 years. Parkinson was a pioneer of child safety and the prevention of childhood trauma. He wrote of the resuscitation of near-drowned children and of first aid for injured children. This critical analysis reviews his pioneering description of child abuse and the development of post-abuse hydrocephalus. He wrote the datum description (in English) of the pathophysiology and pathology of appendicitis in children, of fatal rabies in children and highlighted the risk of death even when the biting dog was not clinically rabid. His advocacy for social reform for children's welfare was courageous and pioneering. James Parkinson, hitherto unacknowledged, was a significant founder of the evolving discipline of paediatrics and child health.

A parent-completed developmental questionnaire: Follow up of ex-premature infants

Objective: premature infants are at increased risk of developmental disability. Early identification of problems allows intervention to ameliorate or attenuate problems. A reliable screening tool allows triage of children in this high-risk population by identifying those unlikely to need full developmental assessment. To explore the test characteristics of an established parent-completed developmental assessment questionnaire 'Ages and Stages Questionnaire' (ASQ) in follow up of an Australian population of premature infants. Methodology: One hundred and sixty-seven children born prematurely with corrected ages 12- to 48-months attending the Growth and Development Clinic at the Mater Children's Hospital in Brisbane, Queensland, Australia; 136 questionnaires 'ASQ' were returned completed (81%) and were compared to formal psychometric assessment (Griffith Mental Development Scales for 12- and 24-months, Bayley Mental Development Intelligence Scale for 18-months, McCarthy General Cognitive Intelligence Scale for 18-months). Developmental delay was considered to be present if any of the above psychometric assessments fell below 1.0 standard deviations (SD). The ASQ cut-off used was 2.0 SD (US data derived means and SD). Results: Aggregate results for all age groups comparing ASQ to psychometric assessments as 'gold standards' found the ASQ to have the following test characteristics: sensitivity (90%); specificity (77%); positive predictive value (40%); negative predictive value (98%): % over-referred (20%); % under-referred (1%); % agreement (79%). likelihood ratio for children failing the ASQ was 3.8 and for passing the ASQ was 0.13. Twenty-one children with known disabilities were included in the study and in 14 of these, the ASQ overall score agreed with the psychometric assessment (67%). Conclusion: The high negative predictive value of the ASQ supports its use as a screening tool for cognitive and motor delays in the follow up of ex-premature infants. This would need to be combined with other strategies as part of a comprehensive follow up program for ex-premature infants.

An evidence-based medicine fellowship in a children's teaching hospital

This paper reports the introduction of an evidence-based medicine fellowship in a children’s teaching hospital. The results are presented of a self-reported ‘evidence-based medicine’ questionnaire, the clinical questions requested through the information retrieval service are outlined and the results of an information retrieval service user questionnaire are reported. It was confirmed that clinicians have frequent clinical questions that mostly remain unanswered. The responses to four questions with ‘good quality’ evidence-based answers were reviewed and suggest that at least one-quarter of doctors were not aware of the current best available evidence. There was a high level of satisfaction with the information retrieval service; 19% of users indicated that the information changed their clinical practice and 73% indicated that the information confirmed their clinical practice. The introduction of an evidence-based medicine fellowship is one method of disseminating the practice of evidence-based medicine in a tertiary children’s hospital.

An evaluation of the first year's experience with a low-cost telemedicine link in Bangladesh

In July 1999, the Swinfen Charitable Trust in the UK established a telemedicine link in Bangladesh, between the Centre for the Rehabilitation of the Paralysed (CRP) in Dhaka and medical consultants abroad. This low-cost telemedicine system used a digital camera to capture still images, which were then transmitted by email. During the first 12 months, 27 telemedicine referrals were made. The following specialties were consulted: neurology (44%), orthopaedics (40%), rheumatology (8%), nephrology (4%) and paediatrics (4%). Initial email replies were received at the CRP within a day of referral in 70% of cases and within thee days in 100%, which shows that store-and-forward telemedicine can be both fast and reliable. Telemedicine consultation was complete within three days in 14 cases (52%) and within three weeks in 24 cases (89%). Referral was judged to be beneficial in 24 cases (89%), the benefits including establishment of the diagnosis, the provision of reassurance to the patient and referring doctor, and a change of management. Four patients (15% of the total) and their families were spared the considerable expense and unnecessary stress of travelling abroad for a second opinion, and the savings from this alone outweighed the set-up and running costs in Bangladesh. The latter are limited to an email account with an Internet service provider and the local-rate telephone call charges from the CRP. This successful telemedicine system is a model for further telemedicine projects in the developing world.

Irritative symptoms after colposuspension: Are they due to distortion or overelevation of the anterior vaginal wall and trigone?

Symptoms of bladder irritability are common after incontinence surgery but their cause is unknown. This study tests the hypothesis that irritative symptoms after colposuspension are due to distortion of the trigone. As part of longitudinal follow-up studies, 175 women were examined 6 months to 12 years after either an open or a laparoscopic Burch colposuspension. The main outcome measures were symptoms of bladder irritability (frequency, nocturia and urge incontinence) and ultrasound findings (bladder neck position at rest and on Valsalva, the presence of a colposuspension ridge, ridge depth and ridge distance, and trigonal angle). Two positive associations between ultrasound parameters and symptoms of bladder irritability were observed: urge incontinence was more likely in the presence of bladder neck funneling, and women with nocturia had a higher trigonal angle. Increased distortion of the trigone was associated with a reduced incidence of urge incontinence in the subgroup of patients after laparoscopic colposuspension. The data presented in this study do not support the hypothesis that symptoms of bladder irritability are due to trigonal distortion or overelevation.

The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises

Perineal ultrasound was used to detect and quantify levator activity by measuring the displacement of the internal urethral meatus against the inferoposterior margin of the symphysis pubis, Women who had previously been instructed in pelvic floor muscle exercises were more likely to contract the levator muscle when asked to do so than were those without previous instruction (P

The influence of posture on perineal ultrasound imaging parameters

A prospective clinical study was carried out to evaluate the influence of posture on perineal ultrasound imaging parameters. One hundred and thirty-two consecutive women presenting with symptoms of lower urinary tract dysfunction were examined by multichannel videourodynamics and perineal ultrasound, both supine and standing. Ultrasound included color Doppler imaging when available, i.e. in a subgroup of 99 patients. The position of the bladder neck at rest was higher in the supine position (P

Is the irritable bladder associated with anterior compartment relaxation? A critical look at the 'integral theory of pelvic floor dysfunction'

The 'integral theory of pelvic floor dysfunction', first proposed by Petros and Ulmsten in 1990, claims that anterior vaginal wall relaxation is associated with symptoms of urgency, frequency, nocturia and urge incontinence. A retrospective study was designed to test this hypothesis. Imaging data and urodynamic reports from 272 women suffering from symptoms of lower urinary tract dysfunction were evaluated. Opening of the retrovesical angle, bladder neck descent, urethral rotation and descent of a cystocele during Valsalva were used to quantify anterior vaginal wall laxity None of the tested parameters were associated with symptoms and signs of detrusor overactivity. On the contrary, patients with higher grades of urethral and bladder descent were less likely to suffer from nocturia and urge incontinence and were less likely to leave sensory urgency and detrusor instability diagnosed on urodynamic testing. The findings of this study therefore do not support this hypothesis of the 'integral theory'.

Translabial color Doppler urodynamics

Color Doppler ultrasound is a new method for documenting fluid leakage in the setting of video-urodynamic testing. In order to compare color Doppler ultrasound with traditional fluoroscopic imaging we performed a prospective blinded comparative clinical study. Fifty-two consecutive patients undergoing urodynamic investigations for symptoms of incontinence or prolapse were examined using fluoroscopy and translabial color Doppler ultrasound to document stress leakage. The investigators were blinded to each other's results. Both tests were performed at maximum bladder capacity and with an indwelling 5 Fr microtransducer catheter, in both the supine and the erect positions. Equivalent results for both methods were obtained in 48 out of 52 patients (Cohen's kappa = 0.82). It was therefore concluded that translabial color Doppler ultrasound imaging can reliably demonstrate leakage through the female urethra on Valsalva maneuver or coughing.

The urethral pressure profile and ultrasound imaging of the lower urinary tract

In a prospective study 105 patients with symptoms of stress incontinence underwent video-urodynamic testing, including resting urethral pressure profilometry and translabial ultrasound. The urethral pressure profile (UPP) included maximum urethral closure pressure (MUCP), functional length (FL) and area under the curve (AUC). Ultrasound parameters included urethral thickness, urethral rotation and bladder neck descent, as well as funneling/opening of the internal urethral meatus on Valsalva maneuver. Levator contraction strength was assessed measuring the cranioventral displacement of the internal meatus. Negative correlations between UPP data and age, parity and previous surgery were observed which were consistent with literature data. There was a positive correlation :between the urethral AP diameter on ultrasound and the MUCP, which agrees with reports showing reduced sphincter thickness or volume in stress-incontinent women. Hypermobility on ultrasound did not correlate with UPP data. However, a lower MUCP correlated with extensive opening of the bladder neck. Finally, there was a trend towards poorer pelvic floor function with lower MUCP measurements.