A qualitative study of Australian GPs' attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD)

Background. The importance of general practice involvement in the care of attention-deficit/hyperactivity disorder (ADHD) is increasing due to the rising numbers of patients who present with the disorder. It has been suggested by consensus bodies that GPs should be identifying and referring patients at the severe end of the ADHD spectrum and managing those with less severe symptoms. However, GPs' views of their role in ADHD care are unknown. Objective. Our aim was to explore the attitudes and practices of Australian GPs towards the diagnosis and management of ADHD. Methods. We conducted a series of focus groups to explore GPs' beliefs regarding the causes of ADHD, their perceived role in ADHD diagnosis and management and their views on the role of behaviour therapies and pharmacotherapies in ADHD management. The subjects were 28 GPs in six focus groups. Results. GPs in this study did not want to be the primary providers of care for patients with ADHD. Participants indicated a preference to refer the patient to medical specialists for diagnosis and treatment of ADHD, and expressed low levels of interest in becoming highly involved in ADHD care. Concerns about overdiagnosis and misdiagnosis of the disorder, diagnostic complexity, time constraints, insufficient education and training about the disorder, and concerns regarding misuse and diversion of stimulant medications were the reasons cited for their lack of willingness. Conclusions. The Australian GPs in this study identify a role for themselves in ADHD care which is largely supportive in nature, and involves close liaison with specialist services.

Adjusting prices in the multiple-partners assignment game

Starting with an initial price vector, prices are adjusted in order to eliminate the excess demand and at the same time to keep the transfers to the sellers as low as possible. In each step of the auction, to which set of sellers should those transfers be made is the key issue in the description of the algorithm. We assume additively separable utilities and introduce a novel distinction by considering multiple sellers owing multiple identical objects and multiple buyers with an exogenously defined quota, consuming more than one object but at most one unit of a seller`s good and having multi-dimensional payoffs. This distinction induces a necessarily more complicated construction of the over-demanded sets than the constructions of these sets for the other assignment games. For this approach, our mechanism yields the buyer-optimal competitive equilibrium payoff, which equals the buyer-optimal stable payoff. The symmetry of the model allows to getting the seller-optimal stable payoff and the seller-optimal competitive equilibrium payoff can then be also derived.

Assessing cost-effectiveness in mental health: family interventions for schizophrenia and related conditions

Objective: Existing evidence suggests that family interventions can be effective in reducing relapse rates in schizophrenia and related conditions. Despite this, such interventions are not routinely delivered in Australian mental health services. The objective of the current study is to investigate the incremental cost-effectiveness ratios (ICERs) of introducing three types of family interventions, namely: behavioural family management (BFM); behavioural intervention for families (BIF); and multiple family groups (MFG) into current mental health services in Australia. Method: The ICER of each of the family interventions is assessed from a health sector perspective, including the government, persons with schizophrenia and their families/carers using a standardized methodology. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted. The second stage involves application of 'second filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using multivariate probabilistic sensitivity analysis. Results: The most cost-effective intervention, in order of magnitude, is BIF (A$8000 per DALY averted), followed by MFG (A$21 000 per DALY averted) and lastly BFM (A$28 000 per DALY averted). The inclusion of time costs makes BFM more cost-effective than MFG. Variation of discount rate has no effect on conclusions. Conclusions: All three interventions are considered 'value-for-money' within an Australian context. This conclusion needs to be tempered against the methodological challenge of converting clinical outcomes into a generic economic outcome measure (DALY). Issues surrounding the feasibility of routinely implementing such interventions need to be addressed.

Homicide mortality, socioeconomic development, and police violence in the city of Sao Paulo, Brazil

Objective. To analyze the association between police violence and homicide mortality rates taking into consideration the effect of contextual variables. Methods. This was an environmental, cross-sectional study that included the 96 census districts in the City of Sao Paulo. The association between the variables was analyzed using Spearman`s rank correlation and simple and multiple regression analysis. Results. Univariate analysis revealed a strong and significant association between homicide mortality coefficients and all the indicators of socioeconomic development and police violence. After controlling for potential confounding factors, the association between police violence and homicide mortality coefficients remained strong and significant. This significance was lost only after control for the size of the resident population. Conclusion. The results indicate that police action that violates basic human rights is not the right answer to urban violence. The combination of homicides from interpersonal violence and deaths from police violence results in negative socialization and promotes further violence.

Reductionism and the human duplication thought-experiment

The human duplication thought-experiment is examined, and basic positions concerning the possible outcomes of the experiment are spelled out. A first position sustains supervenience, either from a reductionist or an emergentist perspective, and such views are contrasted. Certain moral aspects of the thought-experiment are then considered, especially in relation to the idea of death. Taking reductionism as a working hypothesis, two possibilities are suggested for investigating the hard problem of qualia: the postulation of some novel sort of physical interaction, and the postulation of a counter-intuitive law of scaling. One possibility for the latter would lead to a violation of supervenience.

Cardiac troponin T as a biochemical marker of cardiac dysfunction and ductus venosus Doppler velocimetry

Objectives: The aim of this study was to determine the correlation between ductus venosus (DV) Doppler velocimetry and fetal cardiac troponin T (cTnT). Study design: Between March 2007 and March 2008, 89 high-risk pregnancies were prospectively studied. All patients delivered by cesarean section and the Doppler exams were performed on the same day. Multiple regression included the following variables: maternial age, parity, hypertension, diabetes, gestational age at delivery, umbilical artery (UA) S/D ratio, diagnosis of absent or reversed end-diastolic flow velocity (AREDV) in the UA, middle cerebral artery (MCA) pulsatility index (131), and DV pulsatility index for veins (PIV). Immediately after delivery, UA blood samples were obtained for the measurement of pH and cTnT levels. Statistical analysis included the Kruskal-Wallis test and multiple regressions. Results: The results showed a cTnT concentration at birth >0.05 ng/ml in nine (81.8%) of AREDV cases, a proportion significantly higher than that observed in normal UA S/D ratio and UA S/D ratio >p95 with positive diastolic blood flow (7.7 and 23.1%, respectively, p < 0.001). A positive correlation Was found between abnormal DV-PIV and elevated cTnT levels in the UA. Multiple regression identified DV-PIV and a diagnosis of AREDV as independent factors associated with abnormal fetal cTnT levels (p < 0.0001, F(2.86) = 63.5, R = 0.7722). Conclusion: DV-PIV was significantly correlated with fetal cTnT concentrations at delivery. AREDV and abnormal DV flow represent severe cardiac compromise, with increased systemic venous pressure, and a rise in right ventricular afterload, demonstrated by myocardial damage and elevated fetal cTnT. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Sequential Changes of Longitudinal and Radial Myocardial Deformation Indices in the Healthy Neonate Heart

Background: Significant hemodynamic changes, including preload and afterload modifications, occur during the transition from the fetal to the neonatal environment. The ductus arteriosus closes, pulmonary vascular resistance decreases, and pulmonary blood flow increases. Strain rate (SR) and strain (e) have been proposed as ultrasound indices for quantifying regional wall deformation. This study was designed to determine if these indices can detect variations in regional deformation between early and late neonatal periods. Methods: Data were obtained from 30 healthy neonates (15 male). The initial study was performed at a mean age of 20.1614 hours (exam 1) and the second at 31.962.9 days (exam 2). Apical and parasternal views were used to quantify regional left ventricular (LV) and right ventricular (RV) longitudinal and radial SR and e, and systolic, early, and late diastolic values were calculated from these curves. A paired-samples t test was performed comparing the two groups. Results: Compared with exam 1, LV radial deformation showed significant reductions in peak systolic e in the basal and mid segments (51615% vs 4669%, P < .01). LV longitudinal deformation behaved similarly, showing significant peak systolic e reductions in all measured segments. Systolic SR showed reductions only in the basal and apical segments of the lateral wall and in the mid portion of the inferior wall (-1.9 +/- 0.5 vs -1.7 +/- 0.3 s(-1) and -1.9 +/- 0.4 vs -1.7 +/- 0.2 s(-1), respectively, P = .03). RV longitudinal free and inferior wall systolic SR and e values were significantly higher in exam 2. Conclusions: LV peak systolic e decreases in exam 2 were possibly due to afterload increase and preload decrease. The lower RV initial deformation indices could be attributed to increased afterload caused by physiologic pulmonary hypertension or immature RV contractile properties. SR seemed to be a more robust index than e and less influenced by preload and afterload hemodynamic alteration. (J Am Soc Echocardiogr 2010;23:294-300.)

Lepocreadiid (Digenea) species from members of the marine teleost family Cheilodactylidae from south-western Australia, including four new genera and five new species

The following lepocreadiid species are described from Cheilodactylidae from south-western Australia. Cliveus peroni n. g., n. sp, from Nemadactylus valenciennesi is characterised by its attenuated forebody and C. acaenodera n. sp. from Dactylophora nigricans by its attenuated forebody, the pattern of forebody spination and the large cirrus-sac. Jericho chojeri n. g., n. sp. from N. valenciennesi has a large infundibuliform oral sucker and paired ani. Rugocavum n. g. is distinguished by the possession of a blind, wrinkled glandular pit on the postero-ventral surface of the forebody. R. nemadactyli n. sp. from N. valenciennesi has its vitelline field restricted to the hindbody, whereas in R. morwong n. sp, from N. valenciennesi the vitelline field reaches into the forebody. Paraneocreadium australiense Kruse, 1978 from N. valenciennesi is redescribed and its coiled internal seminal vesicle and lobed gonads are considered distinctive features. Scaphatrema nemadactyli (Kurochkin & Korotaeva, 1972) n. g., n. comb. from N. valenciennesi has a wrinkled, boat-shaped body, a 'Lepidapedon-like' cirrus-sac and multiple testes; it was originally placed in the genus Multitestis, but these characters suggest that a new genus should be erected for it within the subfamily Lepidapedinae.

Bazex-Dupre-Christol syndrome in a 1-year-old boy and his mother

Bazex - Dupre - Christol syndrome is a rare genodermatosis with cancer predisposition, characterized by follicular atrophoderma, multiple milia, congenital hypotrichosis, hypohidrosis and basal cell malformations that include nevoid basal cell carcinomas of early onset. We present two patients with this syndrome, a 1-year-old boy with diffuse scalp and eyebrows alopecia, milia papules on the face, ears, trunk, and limbs. Hypohidrosis was observed on his trunk and head. His 16-year-old mother had identical changes since childhood, with hair fragility, and multiple atrophic ""ice pick"" follicular depressions on the dorsa of her hands. She also had a basal cell carcinoma on her face. Microscopic examination of hairs from the mother revealed abnormalities such as diameter irregularities, broken shafts, trichorrexis nodosa and pili bifurcatti. Pili bifurcatti is an uncommon hair shaft dysplasia that has not before been observed in Bazex - Dupre - Christol syndrome.

Correlation of fungi and endotoxin with PM2.5 and meteorological parameters in atmosphere of Sao Paulo, Brazil

Particulate matter, especially PM2.5, is associated with increased morbidity and mortality from respiratory diseases. Studies that focus on the chemical composition of the material are frequent in the literature, but those that characterize the biological fraction are rare. The objectives of this study were to characterize samples collected in Sao Paulo, Brazil on the quantity of fungi and endotoxins associated with PM2.5, correlating with the mass of particulate matter, chemical composition and meteorological parameters. We did that by Principal Component Analysis (PCA) and multiple linear regressions. The results have shown that fungi and endotoxins represent significant portion of PM2.5, reaching average concentrations of 772.23 spores mu g(-1) of PM2.5 (SD: 400.37) and 5.52 EU mg(-1) of PM2.5 (SD: 4.51 EU mg(-1)), respectively. Hyaline basidiospores, Cladosporium and total spore counts were correlated to factor Ba/Ca/Fe/Zn/K/Si of PM2.5 (p < 0.05). Genera Pen/Asp were correlated to the total mass of PM2.5 (p < 0.05) and colorless ascospores were correlated to humidity (p < 0.05). Endotoxin was positively correlated with the atmospheric temperature (p < 0.05). This study has shown that bioaerosol is present in considerable amounts in PM2.5 in the atmosphere of Sao Paulo, Brazil. Some fungi were correlated with soil particle resuspension and mass of particulate matter. Therefore, the relative contribution of bioaerosol in PM2.5 should be considered in future studies aimed at evaluating the clinical impact of exposure to air pollution. (C) 2010 Elsevier Ltd. All rights reserved.

Increased Serum IL-1 beta Level in Alzheimer`s Disease and Mild Cognitive Impairment

Background/Aims: Abnormal inflammatory response has been associated to the pathogenesis of Alzheimer`s disease (AD) and may be a marker of an ongoing neurodegenerative process. The aim of this study was to evaluate the serum levels of interleukin-1 beta (IL-1 beta) in patients with mild cognitive impairment (MCI) and AD. Methods: One hundred and sixty-three older adults ( 58 with mild to moderate AD, 74 with MCI and 31 healthy controls) were recruited for this study. Serum IL-1 beta levels were measured by ELISA. Patients with MCI were subcategorized in single-domain amnestic (aMCI), nonamnestic (naMCI), and multiple-domain (mdMCI) subtypes. Results: Patients with AD and MCI ( all subtypes) had a significant increase in serum IL-1 beta levels as compared to controls (p = 0.03). Patients with mdMCI had serum IL-1 beta levels comparable to those with AD, and significantly higher than those observed in aMCI and naMCI ( p = 0.02). Discussion: The present study provides evidence that inflammatory mechanisms, represented by elevated IL-1 beta, are observed in patients with MCI, specifically in those with impairment in multiple cognitive domains. As these patients are at higher risk of conversion to dementia, we propose that an increased serum IL-1 beta level is a stage marker of the ongoing brain neurodegeneration in the continuum between normal ageing and AD. Copyright (C) 2009 S. Karger AG, Basel

Paracoccidioidomycosis in Patients Infected with and Not Infected with Human Immunodeficiency Virus: A Case-Control Study

Epidemiologic and clinical data for 53 patients with paracoccidioidomycosis and co-infected with human immunodeficiency virus (HIV) (cases) were compared with those for 106 patients with endemic paracoccidioidomycosis (controls). The prevalence of Paracoccidioides brasiliensis co-infection was estimated in 1.4% in cases of acquired immunodeficiency syndrome (AIDS). Patients co-infected with HIV were younger, less involved in agricultural occupations; 83.7% had CD4+ cell count < 200 cells/mu L. Paracoccidioidomycosis in co-infected patients usually showed a rapid progression, with more fever, frequent involvement of the lungs, and multiple extrapulmonary lesions. The response to antifungal therapy and deaths caused by paracoccidioidomycosis were similar in the two patient groups, but late relapses were more common in co-infected cases. Paracoccidioidomycosis in HIV-infected patients shows epidemiologic and clinical characteristics differing from those of the endemic disease and should be considered an AIDS-defining opportunistic infection in Latin America.

The impact of perinatal and socioeconomic factors on mental health problems of children from a poor Brazilian city: a longitudinal study

Low birth weight and preterm birth, and social disadvantage may negatively affect mental health of children, but findings have been inconsistent. To assess the influence of perinatal and social factors on mental health problems in children aged 7-9 years. A random sample of 805 births in So Luis, Brazil was studied in 1997/1998 and again in 2005/2006. Perinatal, socioeconomic and demographic variables were assessed within 24 h after delivery. The Strengths and Difficulties Questionnaire (SDQ) was used to assess mental health problems in the children. Simple and multiple Poisson regressions were used for statistical analysis. The overall prevalence of mental health problems in the total sample was 47.7%. The prevalences of emotional and conduct problems were 58.2 and 48.8%, respectively. Only paternal age (< 20 years) was associated with mental health problems as measured by the full SDQ scale (prevalence ratio PR = 1.27). Children born to single mothers (PR = 1.31) and those with birth weight from 1,500 to 2,499 g (PR = 1.18) and from 2,500 to 2,999 g (PR = 1.17) had a higher risk of emotional problems, but those from low income families had a lower risk (PR = 0.80). Children with a father of less than 20 years had a higher risk of having problems with their peers (PR = 1.75). A maternal education of 9 years or over was inversely associated with peer (PR = 0.70) and conduct problems (PR = 0.73). Girls had a lower risk of conduct (PR = 0.77) and hyperactivity problems (PR = 0.68). A maternal education of 4 years or less increased the risk of hyperactivity (PR = 1.48). Socioeconomic and demographic conditions were better predictors of mental health problems in children than birth weight or preterm birth. However, since most effect sizes were small most mental health problems were, unexplained by the variables in the study.

Birth weight and bone mass in young adults from Brazil

Background: Birth weight is positively associated with adult bone mass. However, it is not clear if its effect is already evident in early adulthood. Objective: To investigate the association between birth weight, adult body size, the interaction between them and bone mass in young adults. Methods: Bone densitometry by DXA was performed on 496 individuals (240 men) aged 23-24 years from the 1978/79 Ribeirao Preto (southern Brazil) birth cohort, who were born and still residing in the city in 2002. Birth weight and length as well as adult weight and height were directly measured and converted to z-scores. The influence of birth weight and length, and adult weight and height on bone area (BA), bone mineral content (BMC) and bone mineral density (BMD) at the lumbar spine, proximal femur and femoral neck were investigated through simple and multiple linear regression models. Adjustments were made for sex, skin color, gestational age, physical activity level, smoking status and dietary consumption of protein, calcium and alcohol. Interaction terms between birth weight and adult weight, and birth length and adult height were tested. Results: Men in the highest fertile of birth weight distribution had greater BA and BMC at all three bone sites when compared with their counterparts in the lowest tertiles (p<0.008). For BMD, this trend was observed only in the lumbar spine. Adult weight and height were positively associated with BA and BMC at all three bone sites (p<0.05). For BMD, these associations were seen for adult weight, but for adult height an association was observed only in the lumbar spine. Birth weight retained positive associations with proximal femur BA and BMC after adjustments for current weight and height. No interaction was observed between variables measuring prenatal growth and adult body size. Conclusion: Birth weight and postnatal growth are independent determinants of adult bone mass in a sample of Brazilian adults. This effect is already evident in early adulthood. (C) 2010 Elsevier Inc. All rights reserved.

The rise of multiple births in Brazil

Aim: The aim of this study was to assess the rise in multiple births and its influence on trends of low birth weight (LBW) rates in Porto Alegre, Brazil. Methods: This is a registry-based study of live births from 1994 to 2005 obtained from the national live birth information system. Chi-square tests for trends were assessed for LBW and multiple birth rates. The impact of multiple births on LBW trends was assessed by sequential modelling, including year and further adjustment for multiple births. Risk factors for multiple births were assessed using the Poisson regression. Results: A total of 263 252 live births were studied. The LBW rate increased from 9.70% to 9.88% (p < 0.001) and the multiple birth rate rose from 1.95% to 2.53% (p < 0.001). LBW rate increased among twins, from 57.14% to 63.46% (p = 0.001). The twin birth rate rose by 24.7%, while the rate of triplets or higher-order increased by 150%. Multiple births may be responsible for 23.9% of the increase in the LBW rate over the period. Mothers with higher levels of schooling, older mothers and mothers delivering in private hospitals were more likely to deliver multiple births. Conclusions: It seems that both the increase in multiple births and in the LBW among multiple births contributed to this rise in overall LBW rate.