Epidural abscess following epidural steroid and local anaesthetic injection

Epidural abscess is a well-recognised but rare complication of epidural catheter placement. We have found only five previous reports of epidural abscess from noncatheter-related administration of steroids and/or local anaesthetic. We describe a further case which led to critical illness and emphasise the association between diabetes mellitus and epidural infection.     

A pilot study of a parent-education group for families affected by depression.

OBJECTIVE: This study assessed the feasibility and efficacy of a parent-education group for families with young children and a parent with depression. We designed the program to be readily disseminated if shown to be effective. METHOD: We recruited 44 parents with depression from clinics and family doctors in Hamilton, Ontario, and randomly assigned them to receive the parenting program or to a wait-list control group. The outcomes measured included knowledge of depression, parenting, family relationships, depression symptoms, child depressive symptoms, and functioning. We used analysis of covariance to test for posttreatment differences between experimental and control groups. RESULTS: Of the treatment group, 27% dropped out at posttreatment, and 43% by follow-up. Those who dropped out had more severe depression at baseline than did those who completed the program, and there was selective loss of parents with more severe depression in the experimental group. In intention-to-treat analyses at posttreatment, probands in the experimental group reported more improvements on family functioning, parenting sense of competence, and family and parent conflict than did control subjects. Standardized effect sizes (ES) were medium (0.4 to 0.6). When baseline depressive symptom scores were controlled in the analyses, the between-group differences were reduced, showing that selective loss of participants may have influenced the findings. CONCLUSIONS: On balance, the results are encouraging and support the further development and evaluation of the group intervention. However, the study does not provide unequivocal evidence in support of the program. Before it is transferred to other settings, the program needs further modification to improve participation by parents with more severe depression and further evaluation of its effectiveness.     

The onset of tense marking in children at risk for specific language impairment.

PURPOSE: The purpose of this study was to develop and evaluate measures reflecting the onset of tense marking for children between the ages of 2;0 (years;months) and 3;0. METHOD: The validity of 4 cumulative measures of tense marker emergence and productivity was evaluated relative to existing measures of early grammatical development in a sample of 20 children followed longitudinally. Fourteen children were at risk for specific language impairment (AR-SLI group), and 6 children had low average language abilities (LA group). RESULTS: All measures of onset were highly correlated with the traditional measures; however, children's progress toward mastery of grammatical tense marking was best explained by the productivity of their tense marking systems. Finally, the onset measures imposing productivity requirements best differentiated children in the LA group from those in the AR-SLI group. CONCLUSIONS: The clinical implications for using the late onset of tense marking to improve the early identification of SLI are discussed.     

Emergency Preparedness for Health Professionals in a Statewide AHEC Program: the first two years.

In 2003 through 2005, the California Statewide Area Health Education Centers (AHEC) Program developed an educational delivery system, through partnerships with six AHECs and state organizations concerned with emergency preparedness, to train for public health emergency preparedness the health professionals who practice primarily in the state's medically underserved areas. Four educational modules--General Emergency Preparedness, Bioterrorism, Chemical and Radiologic Agents, and Emerging Infections--were developed and delivered by a trained, multidisciplinary, community-based faculty. The authors discuss the organization, partnerships, curriculum, faculty, characteristics of trainees, outcomes of the program, effects for AHECs, and the evaluation used to commit the organization and program process to the intended program objectives during the two-year period. Over 9,000 health professionals attended one or more of the 462 educational presentations. Approximately one third of attendees were physicians, and 82% of the learners were from sites that typically care for the underserved. Important to the success of the program (which still continues in a revised form) were the types of partnerships, an orientation of the curriculum to all-hazards disaster preparedness, the delivery of educational sessions at clinical sites, and the increased capacities of community AHECs to facilitate continuing professional education. The challenges were the diminished role of a key partner organization, uncertainties within the funding agency, and the widespread geographic area to address.     

Application of magnetic resonance imaging to evaluation of femoral neck structure in growing girls.

Conventional density measures by dual-energy X-ray absorptiometry (DXA) are confounded by increases in bone size and do not assess bone geometry. We assessed precision of magnetic resonance imaging (MRI) and used MRI, DXA, and hip structure analysis (HSA) to assess 7-mo changes in bone structure at the femoral neck in 18 prepubertal girls. At baseline, girls were 10.4 (0.5) yr, 144.0 (8.2) cm, and 35.2 (7.0) kg, on average. Total bone and cortical cross-sectional area (ToA and CoA) were calculated from high-resolution T1-weighted MRI oblique axial images of the femoral neck. We used proximal femur DXA scans (Hologic QDR-4500) and the HSA program to estimate bone cross-sectional area (CSA), and calculate section modulus. MRI precision was determined by scanning 10 volunteers (13-46 yr old) three times with and without repositioning. Precision (CVrms) was 2% for ToA and 7% for CoA. Significant correlations were observed between FN area and MRI-derived ToA (r = 0.57, p = 0.013) and CoA (r = 0.47, p = 0.050). There were significant positive changes over 7 mo by both methods. In conclusion, MRI provides useful information on femoral neck bone area in children. The reproducibility of cortical dimensions at the femoral neck needs improvement through technical modifications and appropriate analysis software.     

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as ‘the sick role’ and the labelling of patients as ‘good’ or ‘bad’. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources - especially suitably qualified and trained nursing staff- are a negative influence on building the relationships which are vital to successful rehabilitation.