The therapy of pre-school wheeze: appropriate and fair?

The current study aimed to assess prevalence and distribution of use of asthma medication for wheeze in pre-school children in the community. We sent a postal questionnaire to the parents of a random population-based sample of 4,277 UK children aged 1-5 years; 3,410 participated (children of south Asian decent were deliberately over-represented). During the previous 12 months, 18% of the children were reported to have received bronchodilators, 8% inhaled corticosteroids (ICS) and 3% oral corticosteroids. Among current wheezers these proportions were 55%, 25%, and 12%, respectively. Use of ICS increased with reported severity of wheeze, but did not reach 60% even in the most severe category. In contrast, 42% of children receiving ICS reported no or very infrequent recent wheeze. Among children with the episodic viral wheeze phenotype, 17% received ICS compared with 40% among multiple-trigger wheezers. Use of ICS by current wheezers was less common in children of South Asian ethnicity and in girls. Although a high proportion of pre-school children in the community used asthma inhalers, treatment seemed to be insufficiently adjusted to severity or phenotype of wheeze, with relative under-treatment of severe wheeze with ICS, especially in girls and South Asian children, but apparent over-treatment of mild and episodic viral wheeze and chronic cough.

Australian occupational therapists' use of an online evidence-based practice database (OTseeker)

Introduction: Online databases can support the implementation of evidence-based practice by providing easy access to research. OTseeker (www.otseeker.com), an electronic evidence database, was introduced in 2003 to assist occupational therapists to locate and interpret research. Objectives: This study explored Australian occupational therapists' use and perceptions of OTseeker and its impact on their knowledge and practice. Methods: A postal survey questionnaire was distributed to two samples: (i) a proportionate random sample of 400 occupational therapists from all states and territories of Australia, and (ii) a random sample of occupational therapists working in 95 facilities in two Australian states (Queensland and New South Wales). Results: The questionnaire was completed by 213 participants. While most participants (85.9%) had heard of OTseeker, only 103 (56.6%) had accessed it, with lack of time being the main reason for non-use. Of the 103 participants who had accessed OTseeker, 68.9% had done so infrequently, 63.1% agreed that it had increased their knowledge and 13.6% had changed their practice after accessing information on OTseeker. Conclusion: Despite OTseeker being developed to provide occupational therapists with easy access to research, lack of time was the main reason why over half of the participants in this study had not accessed it. This exploratory research suggests, however, that there is potential for the database to influence occupational therapists' knowledge and practice about treatment efficacy through access to the research literature.

A universally delivered CBT based intervention in a Scottish secondary school: a pilot feasibility study

Objectives: To evaluate the feasibility of a universally delivered CBT-based programme for pupils within a Scottish secondary school setting. Design: A pre-post, within and between groups design was utilised. Setting: Religious Moral Citizenship and Education (RMCE) classes in a Scottish secondary school. Participants: Four (n = 103) classes of third year secondary school pupils were arbitrarily allocated to two conditions: RMCE-as usual (RMCE-AU) controls, and LLTTF intervention. Intervention: Living Life to the Full (LLTTF) is a series of Cognitive Behavioural Therapy (CBT)-based booklets and accompanying 8 classes to improve coping skills. An adolescent version of LLTTF was recently developed. This was delivered over nine weeks by school teachers trained in the approach. Outcome measures: The Strengths and Difficulties Questionnaire, Rosenberg Self-Esteem scale, General Self-Efficacy Scale, and Locus of Control scale were administered at baseline and 9 week follow-up. To determine acceptability and utility of the materials course feedback was gathered weekly from the intervention group and a focus group (n=5) was conducted at 3 month follow up. Results: Outcome measures showed no significant improvement in overall wellbeing of those in the intervention group compared with that of the control group. Weekly feedback suggested that the majority of pupils found the materials useful and relevant. Focus group feedback suggested that pupils found the intervention useful, had utilised strategies in everyday life and would welcome recurring provision of such interventions within the school setting. Conclusions: Universally delivered CBT intervention is acceptable and feasible within the secondary school environment. However, objective measurement using standardised tools does not adequately corroborate qualitative feedback from pupils. Issues relating to measurement, study design and implementation of future interventions are discussed.

Who fails to complete tuberculosis treatment? Temporal trends and risk factors for treatment interruption in a community-based directly observed therapy programme in a rural district of South Africa

SETTING: Hlabisa Tuberculosis Programme, Hlabisa, South Africa. OBJECTIVE: To determine trends in and risk factors for interruption of tuberculosis treatment. METHODS: Data were extracted from the control programme database starting in 1991. Temporal trends in treatment interruption are described; independent risk factors for treatment interruption were determined with a multiple logistic regression model, and Kaplan-Meier survival curves for treatment interruption were constructed for patients treated in 1994-1995. RESULTS: Overall 629 of 3610 surviving patients (17%) failed to complete treatment; this proportion increased from 11% (n = 79) in 1991/1992 to 22% (n = 201) in 1996. Independent risk factors for treatment interruption were diagnosis between 1994-1996 compared with 1991-1393 (odds ratio [OR] 1.9, 95% confidence interval [CT] 1.6-2.4); human immunodeficiency virus (HIV) positivity compared with HIV negativity (OR 1.8, 95% CI 1.4-2.4); supervised by village clinic compared with community health worker (OR 1.9, 95% CI 1.4-2.6); and male versus female sex (OR 1.3, 95% CI 1.1-1.6). Few patients interrupted treatment during the first 2 weeks, and the treatment interruption rate thereafter was constant at 1% per 14 days. CONCLUSIONS: Frequency of treatment interruption from this programme has increased recently. The strongest risk factor was year of diagnosis, perhaps reflecting the impact of an increased caseload on programme performance. Ensuring adherence to therapy in communities with a high level of migration remains a challenge even within community-based directly observed therapy programmes.

Cisplatin-based therapy: A neurological and neuropsychological review

The present paper reviews research in the area of the broad-spectrum chemotherapeutic agent cisplatin (cis-diamminedichloro-platinum II) and examines the implications for clinical neuropsychology arising from the neurological disruption associated with cisplatin-based therapy. The paper begins with a brief review of cisplatin treatment in terms other than survival alone, and examines the side-effects and the potential central nervous system (CNS) dysfunction in terms of neurological symptoms and concomitant implications for neuropsychology. Two main implications for clinical neuropsychology arising from cisplatin therapy are identified. First, cisplatin therapy impacts upon the psychological well-being of the patient, particularly during and in the months following treatment. It is suggested that during this time, a primary role for neuropsychology is to focus upon the monitoring and the active enhancement of the patient's social, psychological and spiritual resources. Second, with regard to neurocognitive changes, the review suggests that (1) neurocognitive assessment may not yield stable results within 8 months following treatment and (2) while perceptual, memory, attentional and executive dysfunction may be predicted following cisplatin treatment, little systematic research has been carried out to investigate such a possibility. Future research might profitably address this issue and also specifically examine the effects of low dosage cisplatin-based therapy and the effects of recently developed neuroprotective agents. Finally, there is some evidence to suggest that women may be more susceptible to neurotoxicity during cisplatin therapy, but no gender-related cognitive effects are reported in the cisplatin literature. Future research could usefully investigate gender differences in association with cisplatin chemotherapy. Copyright (C) 2000 John Wiley & Sons, Ltd.

Transient evoked otoacoustic emissions in 6-year-old school children: a normative study

Great potential has recently been demonstrated for the application of transient evoked otoacoustic emissions (TEOAEs) in screening the hearing of school-aged children. The present study aimed to describe the range of TEOAE values obtained from a large cohort of 6-year-old children in school settings. Results indicated significant sex and ear asymmetry effects on signal-to-noise ratio, response, whole wave reproducibility, band reproducibility and noise levels. A prior history of ear infections was also shown to influence response level, whole wave reproducibility and band reproducibility. The sex, ear and history specific normative data tables derived may contribute to future improvements in the accuracy of hearing screening for 6-year-old school children.

Population-based mammography screening and breast cancer incidence in New South Wales, Australia

To analyse breast cancer incidence trends in New South Wales (NSW), Australia, in relation to population-based mammography screening targeting women aged 50 to 69 years. Trends in age-specific incidence of invasive breast cancers in NSW women aged >= 40 years were examined in relation to mammography screening rates and screening cancer detection rates. Incidence of invasive breast cancer in NSW women increased in all age-groups over 1972 to 2002. The incidence trend for women aged 50 to 69 years showed that the steepest rise was associated with increased participation in population-based mammography screening, which was implemented from 1988 and achieved state-wide coverage in 1995. The elevated incidence of invasive cancer significantly exceeded pre-screening levels, and persisted after rates of initial screens declined. This elevated incidence was sustained by the contribution of cancers diagnosed through subsequent screening, and resulted from increased cancer detection rates in subsequent screens. The recent increase in invasive breast cancer incidence in NSW is associated with mammography screening, and occurred mostly in the target age-group women. Persistence of higher incidence after 1994 was not explicable by inflation of cancer incidence due to detection of prevalent screen cases, but was associated with a trend of increased cancer detection rates in subsequent screening rounds, probably consequent to quality improvements in mammography screening diagnosis.

Recovery of Renal Function in Heart Transplantation Patients After Conversion From a Calcineurin Inhibitor-Based Therapy to Sirolimus

Background. Renal failure is the most important comorbidity in patients with heart transplantation, it is associated with increased mortality. The major cause of renal dysfunction is the toxic effects of calcineurin inhibitors (CNI). Sirolimus, a proliferation signal inhibitor, is an imunossupressant recently introduced in cardiac transplantation. Its nonnephrotoxic properties make it an attractive immunosuppressive agent for patients with renal dysfunction. In this study, we evaluated the improvement in renal function after switching the CNI to sirolimus among patients with new-onset kidney dysfunction after heart transplantation. Methods. The study included orthotopic cardiac transplant (OHT) patients who required discontinuation of CNI due to worsening renal function (creatinine clearance <50 mL/min). We excluded subjects who had another indication for initiation of sirolimus, that is, rejection, malignancy, or allograft vasculopathy. The patients were followed for 6 months. The creatinine clearance (CrCl) was estimated according to the Cockcroft-Gault equation using the baseline weight and the serum creatinine at the time of introduction of sirolimus and 6 months there after. Nine patients were included, 7 (78%) were males and the overall mean age was 60.1 +/- 12.3 years and time since transplantation 8.7 +/- 6.1 years. The allograft was beyond 1 year in all patients. There was a significant improvement in the serum creatinine (2.98 +/- 0.9 to 1.69 +/- 0.5 mg/dL, P = .01) and CrCl (24.9 +/- 6.5 to 45.7 +/- 17.2 mL/min, P = .005) at 6 months follow-up. Conclusion. The replacement of CNI by sirolimus for imunosuppressive therapy for patients with renal failure after OHT was associated with a significant improvement in renal function after 6 months.