The School Nurse as a Coordinator of Health Services for Handicapped Students: A School Record Analysis

Data from a study of linkages between the public schools and private medical practitioners in the care of handicapped children in the elementary grades were used to study the extent to which school nurses act, through screening and referral, as coordinators of health care services for these children. Cumulative school records for a population of 785 students with one or more learning-related handicapping conditions in a single school district were examined. Findings indicated that (1) classroom teachers refer nearly 40 percent of students with handicapping conditions to the school nurse; (2) approximately 33 percent of these students are subsequently referred to physicians for additional medical care (diagnosis and treatment); (3) there are important differences in the likelihood of parental follow-through with nurse referrals for physician care depending on the nature of the child's condition; and (4) where the school and the private medical care system have interacted, parental follow-through with a school nurse referral is more likely. The study suggests that school nurses might play a significant role in assuring continuity of care for children whose physical health is an important factor in determining educational progress.     

Depression characteristics among mildly handicapped students

The present study was conducted to determine the prevalence of depressive characteristics among learning disabled, mentally retarded, and behaviorally disordered students. The influence of sex and age on the prevalence within each handicapping condition was also considered. A “depression subscale” of the Behavior Problem Checklistwas administered to 2078 learning disabled students, 705 behaviorally disordered students, and 1184 nonhandicapped students. The scores were examined via analysis of variance, as well as an extreme-scores analysis using the 95th percentile of nonhandicapped students as a criterion for extremely depressive functioning. The results indicated that (a) behaviorally disordered students, particularly older males, appear more depressed than learning disabled, mentally retarded, and nonhandicapped students; (b) mentally retarded students, particularly younger girls, appear more depressed than the nonhandicapped; (c) learning disabled students are not seen as significantly more depressed than nonhandicapped students. The extreme-scores analysis also revealed interesting interactions of student age and sex. The results are discussed with reference to the need for effective methods for differentially diagnosing handicapping conditions and depressive disorders. Emphasis is also placed on the need for effective strategies for treating depression in behaviorally disordered and mentally retarded students.     

Attitudes of parents,teachers, and health professionals toward child disabilities

Attitudes toward 20 different handicaps in children were investigated by requesting groups of psychologists, parents of children with handicaps, parents of children without handicaps, special education teachers, and regular classroom teachers to respond to three different attitudinal measures. The measures consisted of an Adoption Scale, calling for degree of acceptance of each condition for adoption; a version of the Semantic Differential Scale, involving ratings of each condition on seven bipolar scales; and a Social Distance scale, measuring the acceptability of children having these handicapping conditions within the community, school, social group, and home. The findings indicated major differences in attitudes attributable to disparate rating groups, handicapping conditions, and measures employed.     

Sonographic Findings in Trisomy 9

Objective. The purpose of this study was to identify the most common prenatal sonographic findings in fetuses with complete trisomy 9. Methods. A retrospective review of all cases of trisomy 9 at 5 participating institutions over a 15‐year interval was conducted. Indications for referral and sonographic findings in each case were reviewed to identify characteristic fetal structural anomalies. Results. Six cases of trisomy 9 are presented. Most patients were referred for abnormal sonographic findings on screening examinations (66%) or advanced maternal age (33%). Fetal heart defects and central nervous system malformations were the most frequent sonographic anomalies seen. Conclusions. Sonographic findings in trisomy 9 are similar to those found in other autosomal trisomies. Because trisomy 9 is uniformly lethal and is not included as part of the standard prenatal aneuploidy screening by fluorescence in situ hybridization analysis, clinicians should be cautious in counseling patients with structurally abnormal fetuses until the full karyotype is available.     

Evaluation of Referral Indications for Fetal Echocardiography in Beijing

Objectives. This study was conducted to evaluate the referral indications for fetal echocardiography (FE) in a tertiary center and to determine which indications were significantly associated with prenatal detection of congenital heart disease (CHD). Methods. The medical records of 1425 consecutive women who underwent second‐ and third‐trimester FE at the Ultrasound Center of Beijing Obstetrics and Gynecology Hospital from March 2003 to December 2007 were reviewed. Referral indications, FE diagnoses, and pregnancy outcomes were collected. Univariate and multivariate logistic regression analyses were performed to identify those referral indications associated with prenatal detection of CHD. Results. In 126 patients (8.8%), CHD was detected prenatally and confirmed postnatally. Logistic regression analysis showed that abnormal cardiac views and extracardiac malformation findings (especially a single umbilical artery) on second‐trimester ultrasound screening were found to have significantly more CHD (P < .001). The adjusted odds ratios were 15.2 (95% confidence interval, 9.85–23.45) and 6.78 (95% confidence interval, 2.38–19.27), respectively. Conclusions. Abnormal cardiac views and extracardiac malformation findings on second‐trimester ultrasound screening were significantly associated with prenatal detection of CHD.     

Medical ethics education: to what ends?

The goals of medical ethics education comprise several dimensions: legal duties to secure informed consent, tell the truth and protect confidentiality; objective competencies that include an understanding of DNR regulations and surrogate decision‐making procedures; discursive moral skills such as moral sensitivity, reciprocity and moral development that combine into the capacity for moral dialogue and debate; and finally, behavioural goals that challenge moral education to nurture a more humane, sensitive and communicative physician. Part one of this paper describes each of these goals, together with some of the inherent difficulties affecting implementation. Part two presents survey data from medical ethics instructors (n = 126) who were asked about the importance of each goal and their ability to successfully achieve each aim. While each goal is highly rated, only those goals associated with legal duties and objective competencies are thought to be achieved with any degree of relative success. Goals associated with character transformation, unique to medical ethics education, are among the most difficult to achieve. Additional empirical data corroborate these impressions. Moreover, it is not clear that medical ethics education has much to do with good care. Empirical data are scarce and the conceptual relationship between ethics and care remains highly problematic. Part three offers a number of divergent interpretations of care and concludes that they have little to do with medical ethics. There is no reason to expect that medical competence should be affected by moral competence. Medical ethics therefore might then be viewed as an educational enhancement: unnecessary for healthy doctoring but desirable among a small percentage of the profession who maintain an interest in ethical problems.     

Sigma metric analysis for performance of creatinine with fresh frozen serum

Background: Six sigma provides an objective and quantitative methodology to describe the laboratory testing performance. In this study, we conducted a national trueness verification scheme with fresh frozen serum (FFS) for serum creatinine to evaluate its performance in China. Methods: Two different concentration levels of FFS, targeted with reference method, were sent to 98 laboratories in China. Imprecision and bias of the measurement procedure were calculated for each participant to further evaluate the sigma value. Quality goal index (QGI) analysis was used to investigate the reason of unacceptable performance for laboratories with σ?Results: Our study indicated that the sample with high concentration of creatinine had preferable sigma values. For the enzymatic method, 7.0% (5/71) to 45.1% (32/71) of the laboratories need to improve their measurement procedures (σ??1.2). Only 3.1–5.3% of the laboratories should improve both of the precision and trueness. Conclusions: Sigma metric analysis of the serum creatinine assays is disappointing, which was mainly due to the unacceptable analytical bias according to the QGI analysis. Further effort is needed to enhance the trueness of the creatinine measurement.     

超声软指标联合母体血清甲胎蛋白和人绒毛膜促性腺激素筛查胎儿染色体异常

目的 观察孕中期超声软指标联合检测血清甲胎蛋白（AFP）和人绒毛膜促性腺激素（HCG）用于筛查胎儿染色体异常的价值。方法 对1 625名接受孕中期产前检查孕妇以常规腹部超声检测胎儿超声软指标，采用免疫层析法检测母体血清AFP和HCG。将胎儿多个超声软指标（≥2个）阳性者归为高危孕妇（高危组），行羊膜腔穿刺术及羊水细胞染色体核型检查；对低危孕妇进行产后随访，与筛查结果进行对比。结果 共检出64胎胎儿染色体异常，包括染色体数目异常35胎、结构异常29胎。于高危组167名中发现40胎胎儿染色体异常，包括染色体数目异常23胎、结构异常17胎。母体血清AFP及HCG水平筛查胎儿染色体异常的敏感度分别为64.60%和98.50%，特异度分别为66.00%和14.40%，曲线下面积（AUC）分别为0.701和0.788，截断值分别为56.24 ng/ml和19.36 ng/ml；母体血清AFP联合HCG筛查胎儿染色体异常的敏感度为71.88%，特异度为93.66%，AUC为0.796。超声软指标联合检测母体血清AFP、HCG诊断胎儿染色体异常的敏感度均高于单项指标（P均<0.05）。结论 孕中期超声软指标联合母体血清AFP、HCG检测可提高检出胎儿染色体异常的敏感度，有效筛选胎儿染色体异常的高危孕妇。     

Pharmacokinetic/pharmacodynamic analysis of vancomycin in ICU patients

Aims To identify the variables affecting vancomycin pharmacokinetics in medical ICU patients and to evaluate the potential efficacy of dosage schedules by PK/PD analysis. Design A retrospective pharmacokinetic analysis of serum levels obtained in routine vancomycin monitoring was performed. Setting A 12-bed general ICU of a university teaching hospital. Patients Forty-six vancomycin-treated ICU patients fitting the following criteria: over 18 years old; more than three concentration data per patient; absence of renal replacement support, cardiac surgery and neoplastic disorders. Interventions Clinical information was collected from the patients' medical records. Details of vancomycin therapy, dosage and blood sampling times were obtained from pharmacokinetic reports. Population analysis were made by the standard two-stage approach. Measurements and main results Vancomycin clearance and distribution volume were estimated individually assuming a one-compartment pharmacokinetic model. PK/PD analysis was performed by Monte Carlo simulation. In the ICU patients, higher Vd (nearly twice the quoted value of 0.72 l/kg) and different vancomycin clearance–creatinine clearance relationship were found. Renal function, the APACHE score, age and serum albumin accounted for more than 65% of drug clearance variability. Vancomycin standard dosages led to a 33% risk of not achieving the recommended AUC_24h/MIC breakpoint for Staphylococcus aureus. Conclusions The population kinetics and PK/PD analyses based on Monte Carlo simulation procedures offer an excellent tool for selecting the therapeutic option with the highest probability of clinical success in ICU patients. Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.     

Echogenic Intracardiac Foci

Objective. The purpose of this study was to evaluate the impact of an echogenic intracardiac focus (EIF) on the risk for fetal trisomy 21 (T21) in populations with differing prevalence of T21. Methods. A retrospective cohort study of pregnancies presenting to our prenatal ultrasound units over 16 years (1990–2006) was conducted. Contingency table analysis of the presence of an EIF and diagnosis of fetal T21 was performed. The groups analyzed included the following: (1) all fetuses with EIF plus other sonographic markers, (2) EIF as an isolated sonographic marker, (3) those younger than 35 years with an isolated finding of EIF, and (4) a group with an isolated finding of EIF excluding those at increased risk for T21 on serum screening. Results. Echogenic intracardiac foci were found in 2223 of 62,111 pregnancies (3.6%), and T21 was diagnosed in 218 pregnancies (0.4%). The presence of an EIF along with other markers was associated with a statistically significant risk for T21 (positive likelihood ratio [LR], 4.4; 95% confidence interval [CI], 3.2–6.0; P < .05). An isolated EIF was not associated with a statistically significant increased risk for T21 in patients younger than 35 years (positive LR, 1.7; 95%, CI 0.7–4.1) and those without abnormal serum screening results for aneuploidy (positive LR, 1.6; 95% CI, 0.8–3.1). Conclusions. The finding of an isolated EIF on prenatal sonography does not significantly increase the risk for fetal T21 in populations not otherwise at an increased risk for the disorder. An isolated EIF should be considered an incidental finding in patients younger than 35 years and in those without abnormal serum aneuploidy screening results.     

Comparison of Single Versus Multiple Echogenic Foci in the Fetal Heart Regarding Risk of Aneuploidy

Objective. The purpose of this study was to investigate whether multiple echogenic cardiac foci (ECF) are associated with an increased risk of fetal trisomy 21 in our patient population. Methods. During a span of 38 months, all women found to have an ECF on obstetric sonography were identified as study patients and grouped into single‐ and multiple‐ECF groups. Age‐ and race‐matched patients were identified as a control group. Fetal anatomic sonographic examinations were assessed for other markers of aneuploidy and major abnormalities. The baseline risk for trisomy 21 was assessed by maternal serum screening or age alone if no serum screening had been performed. Trisomy 21 was assessed by amniocentesis or clinically at birth. Both univariate and multivariate analyses were used to assess for associations with trisomy 21. Results. Six of 71 patients (8.5%) with multiple ECF and 1 of 171 patients (0.6%) with a single ECF had trisomy 21. One of 242 control patients (0.4%) had trisomy 21. Logistic regression found multiple ECF (P < .008), the presence of a major finding or multiple minor findings (P = .0012), and a baseline risk for trisomy 21 of greater than 1 in 100 (P = .003) as independent associations with trisomy 21. Conclusions. Our results suggest that finding multiple ECF is a stronger predictor of trisomy 21 than what is described for a single ECF.     

Diagnostic and Treatment Facilities For Multiple Handicapped Children

1. Physicians should be more aware of the causes, identification, treatment facilities and prognosis of handicapping conditions.     

WKA-1R Robot assisted quantitative assessment of airway management

Object  The emerging field of medical robotics aims tointroduce intelligent tools for physician support. The main challenges for developing efficient medical robotic training systems are simulating real-world conditions of the task and assuring training effectiveness. High anatomic fidelity has been achieved in current systems, but they are limited to provide merely subjective assessments of the training progress. We simulated airway intubation using a unique medical robot and developed objective performance criteria to assess task performance. Materials and methods  A patient simulation robot was designed to mimic real-world task conditions and provide objective assessments of training progress. The Waseda– Kyotokagaku Airway No. 1R (WKA-1R) includes a human patient model with embedded sensors. An evaluation function was developed for the WKA-1R to quantitatively assess task performance. The evaluation includes performance indices and coefficient weighting. The performance indices were defined based on experiments carried out with medical doctors and from information found in the medical literature. The performance indices are: intubation time, jaw opening, incisor teeth force, cuff pressure, tongue force and tube position. To determine the weighting of coefficients, we used discriminant analysis. Results  Experiments were carried out with volunteers to determine the effectiveness of the WKA-1R to quantitatively evaluate their performance while performing airway management. We asked subjects from different levels of expertise (from anesthetists to unskilled) to perform the task. From the experimental results, we determined operator effectiveness using the proposed performance indices. We found a significant difference between the experimental groups by evaluating their performances using the proposed evaluation function (P < 0.05). Conclusions  The WKA-1R robot was designed to quantitatively acquire information on the performances of trainees during intubation procedures. From the experimental results, we could objectively determine operator effectiveness while providing quantitative task assessments.     

Hypnosis as an empirically supported clinical intervention: The state of the evidence and a look to the future

Drawing on the literature reviews of this special issue of the International Journal of Clinical and Experimental Hypnosis (2000), this article summarizes the evidence for the effectiveness of hypnosis as an empirically supported clinical intervention. As a whole, the clinical research to date generally substantiates the claim that hypnotic procedures can ameliorate some psychological and medical conditions, as judged against the Chambless and Hollon methodological guidelines. In many cases, these clinical procedures can also be quite cost-effective. It is probable that with some key empirical refinement a number of other hypnosis treatment protocols will have sufficient empirical documentation to be considered “well-established.” However, it is noted that the Chambless and Hollon guidelines are not particularly well-suited for assessing hypnosis' impact when used adjunctly with other interventions. The article concludes with recommendations regarding the efficacy questions that need to be more fully addressed empirically and offers methodological guidelines for researchers and practitioners.     

Down syndrome in India--diagnosis, screening, and prenatal diagnosis

Down syndrome (DS) is the most common genetic cause of mental retardation. Clinical manifestations are variable, and children have psychomotor impairment, multiple malformations, and medical conditions. Confirmation of the diagnosis is by karyotype analysis. The cytogenetic abnormality can be classified into pure trisomy 21, translocation, or mosaicism. Risk of recurrence depends on the primary cytogenetic abnormality in the proband. Prenatal screening is by biochemical and ultrasound markers in the first and second trimester. Definitive prenatal diagnosis is by analysis of fetal chromosomes in fetal chorionic villi, amniocytes, or cord blood. A noninvasive test for trisomy 21 in maternal blood has been developed by massively parallel shotgun sequencing. Therapeutic studies in Ts65Dn mice suggest an exciting prospect of improvement of learning ability and memory deficits.     

First trimester Down syndrome screening is less effective and the number of invasive procedures is increased in women younger than 35 years of age

Objectives We evaluated the performance of first trimester screening for Down syndrome in women less than 35 years of age (study group) and in women aged 35 years or more (control group) in an unselected low‐risk population. Methods The study group comprised a total of 63 945 women who participated in the first trimester combined screening in public health care in Finland during the study period of 1 May 2002 to 31 December 2008. Women at the age of 35 or more (n = 13 004) were controls. Prevalence of Down syndrome, detection rate, false positive rate and number of invasive procedures needed to detect a single case of Down syndrome were analyzed in both groups. Results The overall prevalence of Down syndrome (n = 73) in the study group was 1:876. The number of detected cases was 54. The detection rate was 74.0% with a false positive rate of 2.8%. Number of invasive procedures needed to detect a single case of Down syndrome was 33. In the control group, the detection rate was 87.0% with a false positive rate of 11.9%. The number of invasive procedures needed to detect a single case of Down syndrome was 15. The differences in detection rate and false positive rate were significant, P < 0.012, P < 0.001, respectively. Conclusion The overall detection rate given for the entire population is an overestimate for a woman younger than the age of 35, which should be taken into consideration when counselling women of that age.     

脑出血患者早期康复介入对恢复期神经功能的影响

Background: Incidence, mortality and handicapping rate are very high. Early, proper and active rehabilitation therapy can decrease handicapping rate, improve function recovery and living quality. We study and analyze rehabilitation methods and curative effects of 84 cerebral hemorrhage cases, results as follow.     

胎儿Meckel-Gruber综合征超声表现

目的 观察胎儿Meckel-Gruber综合征的超声表现。方法 回顾性分析5胎Meckel-Gruber综合征胎儿的产前超声表现、基因检测结果、病理结果及引产后表现。结果 5胎Meckel-Gruber综合征胎儿均经产前超声明确诊断,诊断孕周11⁺⁶~21⁺⁶。产前超声5胎均表现为脑膜（脑）膨出,4胎多囊性肾发育不良,4胎多指（趾）;伴发异常表现包括枕部颅骨缺损3胎,脑积水、Blake囊肿、小眼畸形、脊髓圆锥低位、肢体短小、胫骨短小并成角畸形、足内翻、羊水过少、无羊水各1胎。2胎接受基因检测,1胎结果为CEP290基因c.4240del和CEP290基因c.3777-3778del杂合突变,另1胎为MKS3基因c.1365C>T存在纯合突变。孕妇均选择终止妊娠,引产后大体标本所见与产前超声表现相符。对1胎引产后标本进行尸检,发现双侧多囊性肾发育不良。结论 Meckel-Gruber综合征胎儿超声表现具有特征性,产前超声可于早孕期明确诊断。     

Needle fear among women injecting drug users: a qualitative study

Objective: To describe elements of needle phobia amongst women injecting dug users and discuss the associated health implications.

Design: Qualitative research using in depth interviews.

Participants: Forty‐five injecting drug‐using (IDU) women who had experience of being injected with illicit drugs by other drug users.

Results/Findings: Women injecting drug users displayed elements of needle phobia as they had a strong fear of needles. Most were fearful of needles prior to their first experience of injecting drug use. For some, their fear of needles continued during their later injecting experiences. Being afraid of needles, however, was not limited to injecting drug use as many women feared medical procedures that involved needles. They responded to this by refusing or delaying medical procedures involving needles, including blood tests and immunizations.

Conclusions: Some women IDUs have a strong fear of needles and are concerned about medical procedures involving needles. Clinicians, especially those working with drug users, need to be aware that fear of needles can be a problem for some injecting drug users and this has health and clinical practice implications. Needle fear may potentially affect an injecting drug user's engagement with and receipt of health care. Alternative methods of administration should therefore be investigated if this reduces anxiety and ensures that injecting drug using patients receive necessary health care.     

The usefulness of the serum s100b protein for predicting delayed neurological sequelae in acute carbon monoxide poisoning

Context. Some patients with acute carbon monoxide poisoning will experience delayed neurological sequelae. Several factors associated with delayed neurological sequelae have been reported, but these factors are unsatisfactory for the assessment of unconscious patients. Objective. The aim of this study was to assess the usefulness of the serum S100B protein as a biochemical marker for predicting delayed neurological sequelae. Materials and methods. In this retrospective study, we evaluated the data for patients who visited an emergency medical center once during a period of 7 months. The enrollment criteria were the diagnosis of acute carbon monoxide poisoning and the measurement of the serum S100B level. A standardized extraction using medical records was performed. Result. A total of 71 patients were enrolled, and 10 patients (14.1%) presented delayed neurological sequelae. The delayed neurological sequelae group had a longer duration of carbon monoxide exposure, a longer duration of loss of consciousness, and a worse mental status (p-value <?0.001). In addition, the S100B protein levels were higher in the delayed neurological sequelae group (0.891 vs. 0.063, p-value <?0.001). Multiple logistic regression analysis showed that only the serum S100B protein level was independently associated with the development of delayed neurological sequelae (OR, 120.594; 95% CI, 4.194–3467.220), and a serum S100B protein level of more than 0.165 μg/L predicted the development of delayed neurological sequelae (sensitivity 90%, specificity 87%). Discussion and conclusion. In the present study, the level of serum S100B protein was found to be useful for evaluating acute CO poisoning patients and was found to be an independent predictor of the development of DNS after acute CO poisoning.