General practitioner and paediatrician self-reported capacity for the diagnosis and management of childhood and adolescent overweight and obesity

Aim:  The purpose of the present study was to assess and document the self-reported capacity, knowledge, skill and confidence of Central Coast general practitioners and paediatricians in the identification and management of overweight and obesity in children and adolescents, to investigate the barriers they experience in this area of practice and to consider how the local public sector nutrition service may assist.
Methods:  Forty general practitioners and three paediatricians were interviewed using a semistructured purpose-designed questionnaire.
Results:  Most participating doctors perceived that public sector dietitians are not available to assist them in managing overweight and obese paediatric patients. Few (23%) doctors reported using published guidelines and most reported significant barriers limiting their capacity to identify and manage this patient group effectively. All doctors identified at least one way in which the public health system can better support doctors in this role.
Conclusions:  The findings suggest that many doctors may benefit from increased training and a health system that better remunerates them for the time investment needed to provide management consistent with best practice. Reorientation of local public sector nutrition services may also provide them with better support when managing overweight and obese paediatric clients. Future research should examine the actual practices of doctors and how public sector dietitians can best communicate and interact with them to facilitate effective management of these patients.     

SOME EFFECTS OF DIISOPROPYL PHENOL (ICI 35 868) ON THE PHARMACODYNAMICS OF ATRACURIUM AND VECURONIUM IN ANAESTHETIZED MAN

The effects of a bolus injection of diisopropyl phenol 2 mgkg–1 i.v. and an infusion (150 µg kg–1 min–1for 30 min and 75 µg kg–1 min–l thereafter)on the pharmacodynamics and dose-response curves of atracuriumand vecuronium were studied in 52 healthy (ASA I or II) patients.Under anaesthesia with diisopropyl phenol, the cumulative dose-responsecurves of both myoneural blocking drugs were shifted to theleft when compared with previously reported results. However,there was no clinically significant change in the pharmacodynamicsof either drug after the bolus injection of the blocking drug.Diisopropyl phenol 2 mg kg–1 i.v. administered duringsteady-state infusions of vecuronium and atracurium increasedthe depth of the constant neuromuscular blockade. When diisopropylphenol alone was given to four patients there was no changein the twitch height. These results show that diisopropyl phenol,given according to the regimen in this study, potentiates bothof the neuromuscular blockers studied but does not prolong theduration of action of either drug. During the infusion of diisopropylphenol, vecuronium was found to be five times more potent, tohave a more rapid onset time, and to be shorter acting thanan equipotent dose of atracurium. ^*Present address: Department of Anaesthesia, Royal Infirmary,Glasgow     

Vagal Function in Achalasia of the Cardia

Autonomic nervous function in achalasia of the cardia was assessedby measuring the response of the lower oesophageal sphincterto abdominal compression, the gastric secretory response toinsulin-induced hypoglycaemia and the pulse rate variabilitywith deep respiration. Twenty-eight patients with symptomaticachalasia and 24 age and sex-matched control subjects were studied. Rise in intra-abdominal pressure normally causes a reise inlower oesophageal pressure through a vagally-mediated mechanism.Before treatment this response was unimpaired in eight of 10patients with achalasia. A sub-normal response was found ineight of 10 patients who had previously had pneumatic dilatationof the cardia and in three of four who had had a cardiomyotomy.These abnormalities reflected the effect of treatment in disruptingthe sphincter rather than impairment of its innervation. Thegastric acid secretory response to insulin-induced hypoglycaemia,expressed as a ratio of that to pentagastrin, was normal, ineach of the nine patients studied. Pulse rate variability withdeep respiration, a test of cardiac vegal function, was normalin 22 of 25 patients studied. It is concluded that in achalasia the vagal trunks appear functionallyintact and that the myenteric plexus lesion rarely affects theresponsiveness of the lower oseophageal sphincter to increasein intra-abdominal pressure.     

PROTEIN-A PURIFIED HUMAN IMMUNOGLOBULINS: A COMPARISON OF THYROID STIMULATING AND THYROTROPHIN RECEPTOR BINDING ACTIVITIES IN THYROTOXICOSIS

Protein-A purified human thyroid stimulating immunoglobulins (TSIg) and thyrotrophin binding inhibiting immunoglobulins (TBIIg) were measured in euthyroid subjects and thyrotoxic patients by bioassay and TSH radioligand receptor assay respectively. Unextracted sera from euthyroid and thyrotoxic subjects inhibited both basal and TSH stimulated iodide uptake in the bioassay, which was based on iodide uptake in porcine thyrocytes. Similar effects were seen with Ig and TSIg extracted from sera using either polyethylene glycol or ammonium sulphate. However IgG and TSIg prepared using Protein-A Sepharose CL-4B from sera of euthyroid subjects had little effect in this system. The majority of Protein-A purified TSIg preparations from sera of thyrotoxic patients stimulated iodide uptake in procine thyrocytes in a dose-dependent manner and most (85%) diluted parallel to both bovine and human TSH. TSIg and TBIIg from 73 patients with thyrotoxicosis were assessed using the bioassay and receptor assay and compared to a control group of 35 euthyroid subjects. The median (and range) values for TSIg and TBIIg in the euthyroid group were 4.35 (0.8 to 7.5, % stimulation over control) and 2.7 (-9.3 to 8.6, TBII index) for the bioassay and radioreceptor assay respectively. A value of greater than 10.0 in both assays was taken as a positive result. Of the thyrotoxic patients 61 out of 73 were positive in the bioassay (83.6%) compared to 60 in the radioreceptor assay (82.2%). There was a positive correlation between the two assays (r = 0.821, P less than 0.001). Of the 73 thyrotoxic patients 40 were untreated, 18 had received carbimazole and 15 had been previously treated with iodine-131. TSIg levels in the untreated thyrotoxics were similar to those in either group of treated patients. However they were higher (P less than 0.05) in the iodine-131 group than in the patients treated with carbimazole. Similar results were obtained for TBIIg. The coupling of a specific extraction method for human serum IgG with a bioassay for TSIg has demonstrated a high prevalence of these immunoglobulins in patients with thyrotoxicosis. The agreement between this assay and a radioreceptor assay was good, indicating that TSH displacing and thyroid stimulating activities of these immunoglobulins are closely related.     

RESPONSE OF PLASMA ALDOSTERONE TO FLUDROCORTISONE IN PRIMARY HYPERALDOSTERONISM AND OTHER FORMS OF HYPERTENSION

The response of plasma aldosterone to fludrocortisone administration (400 mug 12-hourly for 3 days) was studied in twenty-two patients with primary hyperaldosteronism. No difference was observed in the response between those patients with an adrenal adenoma and those with bilateral adrenocortical hyperplasia, there being no significant change in plasma aldosterone levels across the test period. No separation between the groups was seen when basal plasma renin concentration was related to the aldosterone level following fludrocortisone. It is concluded that the test is of little value in the pre-operative differentiation of these conditions. Twenty-three patients with no demonstrable cause for their hypertension and four with elevated levels of plasma deoxycorticosterone were similarly studied for comparison. These groups demonstrated a normal fall in plasma aldosterone levels following fludrocortisone.     

Follow-up of Gambian children recruited to a pilot safety and immunogenicity study of the malaria vaccine SPf66

A pilot safety and immunogenicity trial of the malaria vaccine SPf66 was undertaken in The Gambia in 1993. One hundred and fifty infants aged 6–11 months were immunized with either 0.5 mg or 1.0 mg of SPf66 produced either in Colombia or in the USA or with a control vaccine. Children who received SPf66 experienced more clinical attacks of malaria than did children in the control group during the first period of surveillance and the difference in incidence between children who had received high dose Colombian vaccine and the control children was statistically significant at the 5% level. During the 1995 malaria transmission season, 127 children from the original cohort of 150 were observed. During 18 weeks of intensive surveillance, the incidence of clinical malaria was again higher among children who had received SPf66 than among children who had received inactivated polio vaccine (6.23 vs 4.89 clinical attacks per 1000 days at risk), the effect being most marked among children who were in the high dose groups, but differences between groups were now no longer statistically significant .