Dementia Care Mapping reconsidered: exploring the reliability and validity of the observational tool

BACKGROUND: Dementia Care Mapping (DCM) is a widely used observational method for evaluating the service quality provided to people with dementia. However, there is little evidence concerning its reliability and validity when used by routine care staff for whom it was designed. METHOD: The study evaluated levels of inter-observer agreement; The ability of the five-minute time frame to reflect the 'actual passing of time'; And the nature of the relationship between individual Well/Ill-Being values (WIB) and dependency levels.Data collected using DCM and continuous time sampling (CTS) were compared. The methods were used in parallel where the CTS coder and the DCM mapper(s) observed the same participants.Observations were carried out with 64 people with dementia within a day hospital and a continuing care ward. Inter-observer agreement was calculated across 20 participants.Dependency levels were measured using the Clifton Assessment Procedure for the Elderly (CAPE) (Pattie and Gilleard, 1979). RESULTS: Low levels of inter-observer agreement were found where 11 of the 25 Behaviour Category codes and all six Well/Ill-being Codes produced unacceptable kappas (<0.6).The Behaviour coding frame provided a meaningful picture of activities participants engaged in, but significantly underestimated participant levels of inactivity.A strong relationship was demonstrated between participants' WIB score and levels of dependency, thus DCM was unable to measure well-/ill-being as a separate construct from participants' levels of dependency. CONCLUSIONS: Questions were raised regarding the reliability and validity of DCM as used by routine care staff. Possible reasons for this, and suggestions for amendments are made.     

Emotional and behavioural responses to music in people with dementia: an observational study

Using continuous time sampling and direct observation methodology, this study examined the impact of social interaction in music listening on behavioural responses of people with moderate-to-severe dementia (n = 24). Using Kitwood's theory of personhood as a framework, it was hypothesized that levels of well-being and engagement would be greatest during a live music condition compared with recorded and no music conditions and that levels of challenging behaviour would decrease most in the live music conditions compared with the other music conditions. The relationship between severity of cognitive impairment and well-being, engagement and challenging behaviours across conditions was also examined. The findings suggest that live music was significantly more effective in increasing levels of engagement and well-being regardless of level of cognitive impairment. No significant differences across conditions were found for challenging behaviours, but the correlation between these and cognitive impairment revealed mixed results. Clinical implications regarding the use of live music in dementia care settings are highlighted and recommendations for future research of interventions aimed at reducing challenging behaviours are discussed.     

Self-injurious behavior in young boys with fragile X syndrome

In this study, we distributed surveys to 67 families of young boys with fragile X syndrome to determine the prevalence, onset, form, function, location, and correlates of self-injurious behavior. Fifty-five surveys were completed (82%). The mean age of the boys at the time of the survey was 80 months (range = 20-144). Self-injurious behavior (SIB) was reported for 58% of the participants with a mean age of onset of 31 months. The mean number of forms of self-injury was 2 per participant. Biting was the most commonly reported form of self-injury with the fingers and back of the hand disproportionately targeted as the most prevalent self-injury body site. There was no linear increase in risk of SIB with age past 25 months. SIB was reported as most likely to occur following the presentation of difficult task demands or changes in routine. Significant group differences were found between overall ratings of problem behavior for boys with self-injury compared to those without self-injury. Groups did not differ on measures of fragile X mental retardation protein (FMRP), autism status, adaptive behavior, or age first medicated. Results are discussed in terms of future research designed to further elucidate the behavioral phenotype of fragile X syndrome.     

Performance characteristics of a carbon isotope ratio method for detecting doping with testosterone based on urine diols: controls and athletes with elevated testosterone/epitestosterone ratios

Background: Carbon isotope ratio methods are used in doping control to determine whether urinary steroids are endogenous or pharmaceutical. METHODS: Gas chromatography-combustion-isotope ratio mass spectrometry (GC-C-IRMS) was used to determine the delta(13)C values for 5 beta-androstane-3 alpha,17 beta-diyl diacetate (5 beta A), 5 alpha-androstane-3 alpha,17 beta-diyl diacetate (5 alpha A), and 5 beta-pregnane-3 alpha,20 alpha-diyl diacetate (5 beta P) in a control group of 73 healthy males and 6 athletes with testosterone/epitestosterone ratios (T/E) >6. RESULTS: The within-assay precision SDs for 5 beta A, 5 alpha A, and 5 beta P were +/- 0.27 per thousand, +/- 0.38 per thousand, and +/- 0.28 per thousand, respectively. The between-assay precision SDs ranged from +/- 0.40 per thousand to +/- 0.52 per thousand. The system suitability and batch acceptance scheme is based on SDs. For the control group, the mean delta(13)C (SD) values were -25.69 per thousand (+/- 0.92 per thousand), -26.35 per thousand (+/- 0.68 per thousand), and -24.26 per thousand (+/- 0.70 per thousand), for 5 beta A, 5 alpha A, and 5 beta P, respectively. 5 beta P was greater than 5 beta A and 5 alpha A (P <0.01), and 5 beta A was greater than 5 alpha A (P <0.01). The means - 3 SD were -28.46 per thousand, -28.39 per thousand, and -26.37 per thousand for 5 beta A, 5 alpha A, and 5 beta P, respectively. The maximum difference between 5 beta P and 5 beta A was 3.2 per thousand, and the maximum 5 beta A/5 beta P was 1.13. Three athletes with chronically elevated T/Es had delta(13)C values consistent with testosterone administration and three did not. CONCLUSIONS: This GC-C-IRMS assay of urine diols has low within- and between-assay SDs; therefore, analysis of one urine sample suffices for doping control. The means, SDs, +/-3 SDs, and ranges of delta(13)C values in a control group are established. In comparison, testosterone users have low 5 beta A and 5 alpha A, large differences between 5 beta A or 5 alpha A and 5 beta P, and high 5 beta A/5 beta P and 5 alpha A/5 beta P ratios.     

Orbital fractures in children

PURPOSE: To describe the demographics, etiologic factors, clinical presentations, and outcomes of orbital fractures in children. METHODS: This was a retrospective case series of 96 consecutive patients under 18 years of age with orbital fractures presenting to the Massachusetts Eye and Ear Infirmary, including both hospitalized and nonhospitalized patients. RESULTS: Orbital fractures in children were most frequently the result of sports, assault, or motor vehicle accident. The majority of patients did not require hospitalization and were treated as outpatients. The medial wall and floor of the orbit were the most frequent locations of fracture. Approximately half of the patients in this series required surgery, most often for entrapment. There were no cases of persistent diplopia in patients in whom surgery was performed or was not indicated. Associated ocular injuries were observed in half of the patients. CONCLUSIONS: In this series of hospitalized and nonhospitalized patients, orbital fractures in children had a location pattern similar to that most frequently observed in adult patients (floor and medial wall). Orbital fractures in children frequently require surgery. The high prevalence of ocular injury in children with orbital fractures emphasizes the need for a comprehensive ophthalmic evaluation.     

Analysis of mortality in French diabetic patients from death certificates: a comparative study

This study was implemented in France to determine the causes of death in diabetic patients, whether diabetes was mentioned or not on the death certificate, and to assess the underestimation of the prevalence of diabetes at death. Two stratified random samples of death certificates were selected in the national mortality data base. The first included certificates mentioning diabetes as a cause of death (cases). The second, included certificates with no mention of diabetes (controls). For each certificate, a record form was sent to the certifying physician to ascertain diabetes in the first group and to trace unrecorded diabetes in the second group. In case of diabetes, the characteristics of the patient and his disease were collected (age at onset, treatment, complications ...). We obtained complete data for 325 cases and 959 controls. Among cases, 1% of the subjects were not confirmed as diabetic, while almost 10% of the controls were identified as having diabetes. The corresponding ratio of the corrected prevalence at death to that provided by the French statistics was estimated to 4.0 in men and 3.1 in women. Particular features are that 2% of the total diabetic decedents died from acute metabolic complications (diabetic or hyperosmolar coma, acidoketosis, or acute hypoglycemia), and that 33% of the unreported diabetic decedents under 45 died from trauma or poisoning. These results show that in France, the death rates published in the statistics for diabetes dramatically underestimate the impact of diabetes. A high risk of death is linked to this disease, particularly in people aged under 45, a problem that health deciders should address.     

Assembly of large-area,highly ordered,crack-free inverse opal films

Whereas considerable interest exists in self-assembly of well-ordered, porous “inverse opal” structures for optical, electronic, and (bio)chemical applications, uncontrolled defect formation has limited the scale-up and practicality of such approaches. Here we demonstrate a new method for assembling highly ordered, crack-free inverse opal films over a centimeter scale. Multilayered composite colloidal crystal films have been generated via evaporative deposition of polymeric colloidal spheres suspended within a hydrolyzed silicate sol-gel precursor solution. The coassembly of a sacrificial colloidal template with a matrix material avoids the need for liquid infiltration into the preassembled colloidal crystal and minimizes the associated cracking and inhomogeneities of the resulting inverse opal films. We discuss the underlying mechanisms that may account for the formation of large-area defect-free films, their unique preferential growth along the 〈110〉 direction and unusual fracture behavior. We demonstrate that this coassembly approach allows the fabrication of hierarchical structures not achievable by conventional methods, such as multilayered films and deposition onto patterned or curved surfaces. These robust SiO₂ inverse opals can be transformed into various materials that retain the morphology and order of the original films, as exemplified by the reactive conversion into Si or TiO₂ replicas. We show that colloidal coassembly is available for a range of organometallic sol-gel and polymer matrix precursors, and represents a simple, low-cost, scalable method for generating high-quality, chemically tailorable inverse opal films for a variety of applications.     

Reply to discussion of ‘Empirical vs natural weighting in random effects meta‐analysis’

Three discussion papers raise interesting points, but at the end of the day, we continue to recommend that past meta‐analyses which have influenced public policy or clinical paradigms be reanalyzed by unweighted methods. For all future meta‐analyses that employ either (a) fixed effects where concomitant treatment and/or eligibility are diverse or (b) classical random effects weighted methods, unweighted methods should serve as the primary analysis. Other analyses would be reasonable as secondary approaches. Two commentaries suggest that weights are only random to the extent of estimation errors in the between study and within study variance components. We shall demonstrate that even if these components are known, there is still considerable random variability in the weights. In fact, methods that try to weight the estimates inversely proportional to the variance have a number of undesirable properties, including bias, incorrect standard errors, inconsistency (including coverage of confidence intervals), and counter‐intuitive properties that the expectation of the estimator changes both with the number of studies sampled and with constant multiples of sample size across all studies. These adverse properties do not exist for the unweighted approach. From the numerical example of phenylephrine 10 mg, despite the arguments of Waksman, the proper conclusion is that the collection of studies does not constitute evidence‐based support for efficacy in terms of lowering nasal airway resistance. In the final section, we present two compelling examples where questionable inferences were made, with potential major public implications. Copyright © 2010 John Wiley & Sons, Ltd.     

Multiple Synapse Formation: A Possible Compensatory Mechanism for Increased Cell Size in Rat Supraoptic Nucleus

Magnocellular neuroendocrine cells of the rat supraoptic nucleus undergo numerous morphological changes during chronic dehydration of the animal. These changes include increases in cell size, the percentage of neuronal membrane in direct apposition and formation of new multiple synapses (i.e. terminals which form more than one synapse with adjacent somata and/or dendrites). Previous studies of multiple synapse formation in the supraoptic nucleus did not include adjustments for changes in somatic size, thus the full extent of synapse formation relative to increases in cell size was not known. That multiple synapse formation is a compensatory mechanism for increased somatic size was investigated by comparing animals that were either chronically dehydrated (by drinking 2% saline) or were well hydrated. Using morphometric techniques the percentage of somatic membrane contacted by single and multiple synapses was obtained. Estimates of somatic surface area were used together with stereologically derived estimates of the number of synapses per μm² to calculate the number of single and multiple axo-somatic synapses per neuron. Measures of soma-somatic and soma-dendritic membrane apposition and glial coverage were made to confirm earlier estimates of these parameters. Somatic surface area increased by more than 70% in dehydrated animals. Percentage of somatic membrane contacted by single synapses was lower (by 41%) and that contacted by multiple synapses was higher (by 100%) in dehydrated as compared to control animals. The number of single synapses was not different between the two groups but dehydrated animals had more multiple synapses per soma (23) than controls (6). With dehydration, there was an eight-fold increase in the percentage of somatic membrane contacted by adjacent somatic/dendritic membrane. The surface area per somain such direct apposition was fifteen-fold higher in dehydrates compared to controls. Glial processes covered the same proportion of somatic membrane in the two groups, while the actual area covered by glial processes per soma was higher in dehydrated animals. These results are consistent with the hypothesis that multiple synapse formation at least partially compensates for probable relative decreases in synaptic efficacy as synaptic density decreases when cells increase in size due to dehydration. This altered synaptic input as well as the increased direct apposition between adjacent neurons probably contribute to their enhanced activation during periods of increased hormone demand.     

Activation of excitatory amino acid inputs to supraoptic neurons. II. Increased dye-coupling in maternally behaving virgin rats

Electrical stimulation of the lateral olfactory tract (LOT) has been shown to excite, monosynaptically, supraoptic nucleus (SON) neurons in slices of hypothalamus taken from male, virgin female or lactating rats. Only in the last of these, however, did 10 min of 10 Hz stimulation produce an increase in the incidence of Lucifer yellow dye-coupling, an indicator of electrotonic interactions. This coupling is virtually exclusively dendrodendritic. Since virgin females that have been induced to show full maternal behavior have altered dendritic morphology reminiscent of lactating animals (but different from males and untreated virgins) we investigated the effects of LOT stimulation in slices from maternally behaving virgins. Similar to the data for lactating rats, electrical stimulation of this tract, the terminals of which release excitatory amino acid transmitter, increased the incidence of dye-coupling by 112% (P less than 0.01). Also similar to lactating rats, the coupling was dendrodendritic and the increase was due entirely to increasing the number of neurons coupled to the injected neuron. No increase in coupling was seen in stimulated slices from pup-exposed control rats. We conclude that the maternal behaviors engaged in by both real mothers and induced virgins 'primes' the supraoptic neurons to increase coupling in response to olfactory system stimulation. This priming may occur via olfactory and vomeronasal stimulation during such behaviors as sniffing and anogenital licking of the pups. That coupling increased in tissue from maternally behaving virgins comparably to that from nursing mothers further suggests that SON neurons may play a role in maternal behavior independent of its well-documented role in the milk ejection reflex.