The Physician Belief Scale and psychosocial problems in children: a report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network

Clinicians' management of children with psychosocial problems may vary with their attitudes and beliefs. However, we lack sound instruments to assess these factors. This study examined the psychometric properties of the Physician Belief Scale (PBS). A modified version of the PBS was sent to clinicians who participated in two primary care research networks. Using factor analysis, we reduced the PBS to 14 items and 2 subscales. Cronbach's alpha values were high. Female clinicians, those using DSM-IV, and those having completed training earlier rated themselves as more psychosocially oriented. Identification and treatment of psychosocial problems were significantly related to scores on the Belief and Feeling subscale. The PBS provided only a modest amount of information regarding primary care practices. It is not clear if these limitations are attributable to the instrument or the many other barriers to effective psychosocial care.     

The role of the social worker in provincial psychiatric hospitals: an Ontario study

Confusion still exists about the roles and functions of social workers in the mental health care system. The authors discuss this role ambiguity and its effects. They then present and discuss the findings of a study that explored the current role of the social worker in Ontario psychiatric hospitals with the following objectives: to document social workers' major roles and activities; to assess role satisfaction; to assess involvement in decision making; and to identify major types of therapy used.     

An electron microscope study of synaptic contacts in the abdominal ganglion of Aplysia californica.

The fine structure of the abdominal ganglion of Aplysia californica has been studied in preparations fixed by immersion in aldehydes, either directly or after a survival of a few hours in artificial sea water. The central core of neuropil is surrounded by a rind of neuronal cell bodies floating in a subcapsular space containing a loose meshwork of neuronal and glial processes, separated by wide extracellular spaces. Large primary processes with deeply infolded membranes leave the neuronal perikarya and enter the neuropil where they branch into smaller processes containing either neurofilaments, neurotubules or both. Some have the appearance of initial segments. The neuropil is not a homogeneous structure. Rather, four types of zones can be distinguished: (1) zones of fibers of passage coursing together in the neuropil and making few synaptic contacts: (2) zones of neurosecretory fibers containing large granules and dense-core vesicles, again making few synaptic contacts: (3) zones with a great variety of synaptic contacts between medium size and small profiles; and (4) glomerular zones. The differentiated membranes of the synapses are characterized by a slight increase in density and by being regularly parallel to each other. Presynaptic densities are sometimes quite prominent but specialized dense cytoplasmic opacities have never been seen bordering the postsynaptic membranes, i.e., all synapses are of the symmetrical type. Interlemmal opacities vary considerably in density. In zone 3, the synaptic vesicles are of several sizes, are round, oval or flat, and are either clear or filled with different types of dense material. The population of vesicles within a single profile may consist either of a homogeneous group of similar vesicles or of various mixtures of two or three kinds of vesicles. In profiles with mixtures of clear and large dense-core vesicles, it is often only the clear vesicles which agglomerate towards the differentiated membranes. In such cases the large dense-core vesicles lie as a peripheral halo around the clear vesicles. Here, and especially in other large neuronal profiles not forming contact in the plane of section, they can be seen to associate specifically with mitochondria and glycogen. It is proposed that they do not contain neurotransmitters but are related to mitochondrial activities such as the storage of ATP or the movement of calcium ions. In profiles with mixtures of clear and small dense-core vesicles, both types of vesicles often touch the presynaptic membrane, suggesting the release of two transmitters or of a modulator or neurohormone with a transmitter, by a single terminal. Serial synapses are present in this zone. The glomerular zones contain small profiles forming many synaptic contacts, some of which are arranged in such a way as to suggest the existence of "reciprocal" serial synapses.     

Characterization of the interstitial lung diseases via density-based and texture-based analysis of computed tomography images of lung structure and function

RATIONALE AND OBJECTIVES: Efforts to establish a quantitative approach to the computed tomography (CT)-based character ization of the lung parenchyma in interstitial lung disease (including emphysema) has been sought. The accuracy of these tools must be site independent. Multi-detector row CT has remained the gold standard for imaging the lung, and it provides the ability to image both lung structure as well as lung function. MATERIAL AND METHODS: Imaging is via multi-detector row CT and protocols include careful control of lung volume during scanning. Characterization includes not only anatomic-based measures but also functional measures including regional parameters derived from measures of pulmonary blood flow and ventilation. Image processing includes the automated detection of the lungs, lobes, and airways. The airways provide the road map to the lung parenchyma. Software automatically detects the airways, the airway centerlines, and the branch points, and then automatically labels the airway tree segments with a standardized set of labels, allowing for intersubject as well intrasubject comparisons across time. By warping all lungs to a common atlas, the atlas provides the range of normality for the various parameters provided by CT imaging. RESULTS: Imaged density and textural changes mark underlying structural changes at the most peripheral regions of the lung. Additionally, texture-based alterations in the parameters of blood flow may provide early evidence of pathologic processes. Imaging of stable xenon gas provides a regional measure of ventilation which, when coupled with measures of flow, provide for a textural analysis regional of ventilation-perfusion matching. CONCLUSION: With the improved resolution and speed of CT imaging, the patchy nature of regional parenchymal pathology can be imaged as texture of structure and function. With careful control of imaging protocols and the use of objective image analysis methods it is possible to provide site-independent tools for the assessment of interstitial lung disease. There remains a need to validate these methods, which requires interdisciplinary and cross-institutional efforts to gather appropriate data bases of images along with a consensus on appropriate ground truths associated with the images. Furthermore, there is the growing need for scanner manufacturers to focus on not just visually pleasing images, but on quantitatifiably accurate images.     

Pharmacokinetic Model to Describe the Lymphatic Absorption of r-metHu-Leptin After Subcutaneous Injection to Sheep

Purpose. The purpose of this work was to develop a pharmacokinetic model to describe the contribution of the lymphatics to the absorption and bioavailability of r-metHu-Leptin administered by subcutaneous (SC) injection to sheep. Methods. r-metHu-Leptin was administered either by bolus intravenous injection (0.1 mg/kg) into the jugular vein or by SC injection (0.15 mg/kg) into the interdigital space of the hind leg. The SC groups included a non-cannulated control group and a lymph-cannulated group, in which peripheral lymph was continuously collected from a cannula in the efferent popliteal lymph duct. Serum and lymph concentrations were determined by enzyme-linked immunosorbent assay and profiles were modeled using compartmental pharmacokinetic methods. The fraction of the dose reaching the systemic circulation (F _sys) and the proportions of the absorbed dose taken up via the blood (F _blood) and lymph (F _lymph) were determined. Results. Serum and lymph concentration vs. time profiles were well described by a two compartment model with parallel first order absorption into blood and lymph. F _sys for the SC control group was 60.4 ± 8.4%. In the lymph-cannulated group, 21.7 ± 6.4% of the dose was recovered in serum and 34.4 ± 9.7% was recovered in peripheral lymph giving a total fraction absorbed (F _abs) of 56.0 ± 10.3%. F _sys for the SC control group was not significantly different to F _abs in the lymph-cannulated group. Conclusion. This study has shown that the lymph represents the predominant pathway for absorption of r-metHu-Leptin after SC administration.     

Wavefront aberrations following laser in situ keratomileusis and refractive lens exchange for hypermetropia

PURPOSE: To compare the magnitude of aberrations in eyes after elective hypermetropic laser in situ keratomileusis (LASIK) and refractive lens exchange (clear lens replacement). METHODS: Forty-nine patients (92 eyes) had hypermetropic LASIK and 28 (48 eyes) had refractive lens exchange; 23 hypermetropic subjects (41 eyes) were the control group. LASIK was performed with the Nidek EC-5000 excimer laser; ablation zones 5.5 to 6.0-mm in diameter with transition zones 7.5 to 8-mm in diameter. For refractive lens exchange, all but four IOLs were made of foldable acrylic. Aberrations and corneal topography were measured with the Nidek OPD-Scan model ARK-10000 more than 12 months after surgery. The higher-order root-mean-square (HORMS) wave aberrations for combined third to sixth Zernike aberration orders and the Zernike spherical aberration coefficient C(0)(4) at both 4.2-mm and 6.0-mm pupil sizes were calculated. RESULTS: For the LASIK group, surgical refractive change correlated significantly with total, corneal, and internal HORMS and spherical aberrations (except with internal spherical aberration for a 4.2-mm diameter pupil). For the refractive lens exchange group, there were no significant correlations of surgical refractive change with any of these factors. Similarly, there were no significant correlations of refraction with any of these factors for the control group. For a 3-diopter change in refraction with 6-mm pupils, LASIK doubled the total HORMS aberrations. LASIK changed the sign of spherical aberration from positive to negative by increasing the negative asphericity of the anterior cornea. Taking age differences between groups into account, refractive lens exchange increased the total HORMS aberrations by 40% compared with that of the control group, but this was not statistically significant. However, refractive lens exchange significantly increased total spherical aberration. CONCLUSION: Refractive lens exchange was a better refractive procedure than LASIK for minimizing total higher order optical aberrations that accompany hypermetropic refractive surgery.     

Chronic dry eye and regression after laser in situ keratomileusis for myopia

PURPOSE: To examine the relationship between chronic dry eye and refractive regression after laser in situ keratomileusis (LASIK) for myopia. SETTING: Excimer Laser Vision Centre and Centre for Eye Research, Queensland University of Technology, Brisbane, Australia. METHODS: This study was based on a retrospective analysis of a clinical database and a case study series. Data (N = 565 eyes) were collected before and after (2 weeks and 1, 3, 6, and 12 months) LASIK. Three case studies, which highlight appropriate management strategies for LASIK candidates with dry eye, are presented. RESULTS: Regression after LASIK was related to chronic dry eye. It occurred in 12 (27%) of 45 patients with chronic dry eye and in 34 (7%) of 520 patients without (P<.0001). Patients with chronic dry eye had significantly worse myopic outcomes than those without (1 month, P =.02; 3 months, P =.01; 6 months, P =.004; 12 months, P =.008). The risk for chronic dry eye was significantly associated with female sex, higher attempted refractive correction, greater ablation depth, and the following pre-LASIK variables: increased ocular surface staining; lower tear volume, tear stability, and corneal sensation; and dry-eye symptoms before LASIK. The risk for regression was significantly associated with higher attempted refractive correction, greater ablation depth, and dry-eye symptoms after LASIK. Case studies demonstrated that intensive dry-eye treatment may improve the refractive outcome and alleviate the need for enhancement surgery. CONCLUSION: The risk for refractive regression after LASIK was increased in patients with chronic dry eye.     

Episiotomy and perineal repair. An evaluation of resident education and experience

OBJECTIVE: To describe current training practices and experience with episiotomy and perineal repair in obstetrics and gynecology residency programs in the United States. STUDY DESIGN: A questionnaire mailed to all directors of accredited programs in the United States for distribution to fourth-year residents in their last four months of training included 30 questions regarding formal teaching, supervision, experience and repair techniques. RESULTS: A total of 297 of 1,177 (25.2%) residents, representing 47% of programs, responded. The response rates for the various program sizes were: 32.0% for < or = 12 residents, 29.5% for 13-19 residents, 24.6% for 20-24 residents and 18% for > or = 25 residents. Of the residents, 59.9% received no didactics on episiotomy repair techniques; 59.3% had no formal teaching on pelvic floor anatomy; and 27.7% of third-degree repairs were supervised by attending physicians. Of the respondents, 6.8% had repaired > 20 fourth-degree lacerations and 40.3%, > 20 third-degree lacerations. Ten percent of the graduates felt inadequately trained in perineal repair. CONCLUSION: This survey of fourth-year residents from 47% of obstetric programs indicated that the majority of residents received no formal training in pelvic floor anatomy, episiotomy or perineal repair and, when engaged in such activities, had limited supervision.     

Lymphatic absorption of subcutaneously administered proteins: influence of different injection sites on the absorption of darbepoetin alfa using a sheep model.

The relative contribution of the lymph and blood in the absorption of darbepoetin alfa (DA) from different s.c. injection sites was determined using a central lymph-cannulated sheep model. DA was administered to parallel groups either as a bolus i.v. injection (0.5 mug/kg) into the jugular vein or as a bolus s.c. injection (2 mug/kg) into the interdigital space, the abdomen, or the shoulder. In the lymph-cannulated groups, the thoracic lymph duct was cannulated for continuous collection of central lymph, and blood samples were periodically collected via the jugular vein in all the groups. The concentration of DA in serum and lymph was determined by enzyme-linked immunosorbent assay. The total fraction of the dose reaching the systemic circulation and the fractions absorbed via the lymph and the blood were determined. A pharmacokinetic model was constructed to simultaneously fit the data from all the treatment groups. Absorption was essentially complete for all three injection sites in non-lymph-cannulated s.c. groups, but the rates of absorption differed significantly. Based on the modeling results for the lymph-cannulated groups, the lymphatics represented the predominant absorption route for both the interdigital (90 +/- 1%) and the abdomen (67 +/- 9%) injection sites. Fluorescein isothiocyanate dextran visualization studies revealed that the lymph draining the shoulder injection site entered the thoracic lymph duct distal to the point of cannulation, effectively precluding collection of thoracic lymph from this site. For that reason, the contribution of the lymphatics following injection in the shoulder could not be determined using these cannulation procedures.