Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation

A two year prospective study was performed to determine the epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation in the UK and the Republic of Ireland. Cases were notified to the British Paediatric Association Surveillance Unit from September 1992 to August 1994 if a formal case conference had been held for the first time during that period to discuss any of the above conditions. A total of 128 cases were identified: 55 suffered Munchausen syndrome by proxy alone, 15 poisoning, and 15 suffocation; 43 suffered more than one type of abuse. The majority of children were aged under 5 years, the median age being 20 months. On 85% of occasions the perpetrator was the child's mother. In 42% of families with more than one child, a sibling had previously suffered some form of abuse. Eighty five per cent of notifying paediatricians considered the probability of their diagnosis as virtually certain before a case conference was convened. The commonest drugs used to poison were anticonvulsants; opiates were the second commonest. Sixty eight children suffered severe illness of whom eight died. The combined annual incidence of these conditions in children aged under 16 years is at least 0.5/100,000, and for children aged under 1, at least 2.8/100,000.     

A comparison of transnasal and transoral oesophagogastroduodenoscopy*

Transnasal oesophagogastroduodenoscopy (OGD) with a narrow-bore endoscope has been demonstrated to be feasible in unsedated volunteers. The aim of the study was to compare efficacy, safety, patient tolerance and costs between this novel approach to OGD and standard sedated OGD. Sixty day patients were enrolled for either sedated transoral endoscopy with a standard calibre endoscope or for unsedated transnasal endoscopy with a narrow-bore (5.3mm diameter) endoscope. Visualization was unsatisfactory in one examination in each group. The only complications were minor epistaxis in four of the transnasal group and oxygen desaturation below 90% in two of the sedated transoral group. On a 1 (very uncomfortable) to 5 (very comfortable) visual analogue scale, the mean transnasal group score was 3.09, compared with 3.86 in the transoral group (P = 0.013). In the transnasal group, mean procedure room time was 15 min compared with 20 min in the transoral group (P < 0.0003), and mean recovery room time was 7 min compared with 37 min (P < 0.0001). Consumable and pharmaceutical costs were reduced by 65 and 92%, respectively. This study demonstrates that unsedated transnasal OGD is a safe and effective route for OGD and has acceptable patient tolerance. The safety and decreased recovery times offer major cost savings and the potential for this method of OGD to become an office procedure for the investigation of the upper gastrointestinal tract.     

An intracellular study of the contrast-dependence of neuronal activity in cat visual cortex

Extracellular recordings indicate that mechanisms that control contrast gain of neuronal discharge are found in the retina, thalamus and cortex. In addition, the cortex is able to adapt its contrast response function to match the average local contrast. Here we examine the neuronal mechanism of contrast adaptation by direct intracellular recordings in vivo. Both simple (n = 3) and complex cells (n = 4) show contrast adaptation during intracellular recording. For simple cells, that the amplitude of fluctuations in membrane potential induced by a drifting grating stimulus follows a contrast response relation similar to lateral geniculate relay cells, and does not reflect the high gain and adaptive properties seen in the action potential discharge of the neurons. We found no evidence of significant shunting inhibition that could explain these results. In complex cells there was no change in the mean membrane potential for different contrast stimuli or different states of adaptation, despite marked changes in discharge rate. We use a simplified electronic model to discuss the central features of our results and to explain the disparity between the contrast response functions of the membrane potential and action potential discharge in simple cells.      

Circadian rhythm of glomerular filtration rate in patients after kidney transplantation

Within 6 months of a kidney transplantation the graft can beregarded as an organ deprived of its innervation. We analysedwhether the transplanted kidney has a diurnal rhythm of itsglomerular filtration rate (GFR) similar to the GFR rhythm thathas been demonstrated in normal individuals and in patientswith nephrotic syndrome. GFR was measured by inulin clearancesevery 3 h during 1 day of bed-rest and identical food and fluidintake per 3 h in seven patients, 4–7 months after a successfulkidney transplantation, and in 10 healthy volunteers. Similarto these healthy subjects, a normal circadian rhythm of GFRwas detected in all but one patient with a maximum of 57 (range45–82) ml/min in daytime, a minimum of 47 (range 36–70)ml/min during the night and a relative amplitude of 21 (range10–41)%. The circadian rhythm of GFR was absent in thepatient with the lowest value of GFR (39 ml/min). In conclusion,GFR has a circadian rhythm in patients studied within 6 monthsof a kidney transplantation, despite the absence of renal innervation.     

In Search of Excellence. Expanding the Patient-centred Clinical Method: a Three-stage Assessment

Excellence in caring for the patient has been pursued in bettertechnology and better management structures with multidisciplinaryteams. Excellence is increasingly sought through taking thewhole person seriously and in developing better ways of workingwith relationships. This paper traces the growth of ideas andtheir application in a university department of family medicine,toward a holistic and more patient-centred, three-stage clinicalmethod. This three-stage assessment helps the patient and thephysician to deal holistically with the problem. The biological,the psychological and the environmental systems as well as theirinterrelationships are considered as they impact on health andillness. This method of arriving at a ‘best-fit’understanding of a person's problem, by the doctor and the patienttogether, helps to individualize the assessment and management.Excellence is more likely to be found when we care in an individualizedway within a systems understanding.