Secondhand tobacco smoke in children with asthma: sources of and parental perceptions about exposure in children and parental readiness to change

BACKGROUND: Secondhand smoke triggers childhood asthma. Understanding sources of exposure, parental beliefs about exposure, and readiness to change that exposure are important for designing smoke exposure reduction interventions. METHODS: As part of screening for a clinical trial of a smoke exposure reduction intervention, 519 smoke-exposed children 3 to 12 years old with asthma provided urine specimens for cotinine testing, and their primary caregivers completed questionnaires. RESULTS: The urine cotinine to creatinine ratio (CCR) was lowest if neither the primary caregiver nor day-care provider smoked (mean CCR, 14.0; SD, 14.4), greater if either smoked (mean CCR, 22.2; SD, 21.3; and mean, CCR, 26.3; SD, 22.2, respectively), and greatest if both smoked (mean CCR, 39.6; SD, 27.5; p < 0.01). Parental perception of their child's exposure was weakly associated with the child's CCR (r(2) = 0.11, p < 0.001). Most parents (58.3%) reported that tobacco smoke exposure had small/no negative effect on their child's asthma. Substantial proportions of those for whom a specific exposure reduction action was relevant were classified as contemplating, preparing, or had recently taken action to reduce their child's exposure, including smoking cessation (61.3%), keeping the child out of smoke-exposed places (72.7%), and making the child's home (49.2%) and areas out of the home smoke free (66.9%). CONCLUSIONS: Smoking by the primary caregiver and day-care provider are important sources of exposure for children with asthma. Parental assessment of their child's exposure is associated with biologically confirmed exposure but cannot be relied on to assess that exposure. Although the harm of smoke exposure was frequently underestimated, many parents appeared receptive to considering action to reduce their child's exposure. TRIAL REGISTRATION: (Clinicaltrials.gov). Identifier: NCT00217958.     

Electronic trial banks: a complementary method for reporting randomized trials.

BACKGROUND: Randomized clinical trial (RCT) results are often difficult to find, interpret, or apply to clinical care. The authors propose that RCTs be reported into electronic knowledge bases-trial banks-in addition to being reported in text. What information should these trial-bank reports contain? METHODS: Using the competency decomposition method, the authors specified the ideal trial-bank contents as the information necessary and sufficient for completing the task of systematic reviewing. RESULTS: They decomposed the systematic reviewing task into four top-level tasks and 62 subtasks. 162 types of trial information were necessary and sufficient for completing these subtasks. These items relate to a trial's design, execution, administration, and results. CONCLUSION: Trial-bank publishing of these 162 items would capture into computer-understandable form all the trial information needed for critically appraising and synthesizing trial results. Decision-support systems that access shared, up-to-date trial banks could help clinicians manage, synthesize, and apply RCT evidence more effectively.     

Flexible treatment strategies in chronic disease: clinical and research implications.

Multiple treatments are available for nearly all the mood disorders. This range of treatment options adds a new dimension of choice to clinical decision making. In addition to prescribing the best initial treatment, clinicians should have an algorithm for deciding if and when to make subsequent changes in treatment to take advantage of second-line treatment options when necessary. This article aims to 1) show that a wide variety of clinical decisions can be framed as choices among adaptive (within-patient) threshold-based strategies or algorithms, illustrating the generality of the concept; 2) illustrate two ways to design randomized clinical trials to compare treatment strategies with each other to decide which strategy is best; and 3) discuss some of the advantages offered by these designs, in terms of both patient acceptability and adherence to experimental protocols.     

Inter‐rater reliability of the Abnormal Involuntary Movements Scale (AIMS) in a multi‐centre trial: results from Department of Veterans Affairs Cooperative Study #394

The US Department of Veterans' Affairs (VA) conducted Cooperative Study #394 at nine sites to determine whether vitamin E was a safe and effective treatment for tardive dyskinesia (TD). The study used the Abnormal Involuntary Movement Scale (AIMS) to measure TD. To monitor inter‐rater reliability (IRR) on the AIMS, personnel at each site did initial AIMS assessments, on seven occasions, on a set of five unique subjects from videotapes. On four of these occasions raters re‐assessed sets of five subjects from seven to 13 months after their initial ratings. We analysed the initial ratings of 34 videotaped subjects and the second ratings of 19. To measure IRR, we used the intra‐class correlation coefficient (ICC) for each initial or second rating of the sets of interviews. The ICCs ranged from 0.50 to 0.86, and the ICC for the initial ratings over all 34 subjects was good (0.75; 95% confidence interval 0.64 to 0.83). To determine whether there was significant ‘rater drift’ during the study, we performed linear mixed effects regression on the data with fixed effects for rating (initial or second), rater type, and site and a random effect for rating. The results indicated that scores varied little between ratings (about 0.05 points). Copyright © 2000 Whurr Publishers Ltd.     

Panic disorder versus panic disorder with major depression: Defining and understanding differences in psychiatric morbidity

The present study examined the impact of comorbid major depressive disorder (MDD) on psychiatric morbidity, panic symptomatology and frequency of other comorbid psychiatric conditions in subjects with panic disorder (PD). Four hundred thirty-seven patients with PD were evaluated at intake as part of a multicenter longitudinal study of anxiety disorders; 113 of these patients were also in an episode of MDD. Patients were diagnosed by DSM-III-R criteria utilizing structured clinical interviews. The 113 PD/MDD patients were compared with the 324 remaining PD subjects regarding panic symptoms at intake, sociodemographic, quality of life and psychiatric morbidity variables. Differences in frequency of other comorbid Axis I psychiatric disorders were assessed at intake; personality disorders were evaluated twelve months after intake. The results revealed that PD/MDD patients exhibit increased morbidity and decreased psychosocial functioning as compared to PD patients. Personality disorders were more prevalent in the PD/MDD group at six month follow-up assessment; the PD/MDD group also had an increased frequency of posttraumatic stress disorder (PTSD) and more comorbid Axis I anxiety disorders as compared to the PD group. The total number and frequency of panic symptoms was highly consistent between the two patient groups. Depression and Anxiety 5:12–20, 1997. © 1997 Wiley-Liss, Inc.     

开通闭塞冠状动脉策略的全球性研究 GUSTO—Ⅱb（亚组研究）

病人资料 3 289例因急性冠脉综合征而接受溶栓治疗的患者,2274例接受t－PA治疗,1015例接受链激酶治疗。     

The importance of injury as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania

This paper describes rates and causes of injury deaths among community members in three districts of the United Republic of Tanzania. A population-based study was carried out in two rural districts and one urban area in Tanzania. Deaths occurring in the study areas were monitored prospectively during a period of six years. Censuses were conducted annually in the rural areas and biannually in the urban area to determine the denominator populations. Cause-specific death rates and Years of Life Lost (YLL) due to injury were calculated for the three study areas. During a 6 year period (1992-1998), 5047 deaths were recorded in Dar es Salaam, 9339 in Hai District and 11 155 in Morogoro Rural District. Among all ages, deaths due to injuries accounted for 5% of all deaths in Dar es Salaam, 8% in Hai and 5% in Morogoro. The age-standardised injury death rates among men were approximately three times higher than among women in all study areas. Transport accidents were the commonest cause of mortality in all injury-related deaths in the three project areas, except for females in Hai District, where it ranked second after intentional self-harm. We conclude that injury deaths impose a considerable burden in Tanzania. Strategies should be strengthened in the prevention and control of avoidable premature deaths due to injuries.     

Improving the validity of FH-RDC diagnosis of major affective disorder in uninterviewed relatives in family studies: A model based approach

Analysis of family history and family study diagnoses of major affective disorder in 4806 relatives of affectively ill probands from the NIMH Collaborative Study of the Psychobiology of Depression (Clinical) suggests that rates of disorder in uninterviewed relatives are greatly underestimated by family history. The implications of these underestimates for family and genetics analyses using the family history method are discussed, and other estimates are developed that have better statistical properties. Using the Model Based Direct Adjustment method, the rate of major affective disorder in all relatives (interviewed and uninterviewed) is estimated to be 32%, compared to 25% by the consensus (standard) method, which uses the Family History-RDC interview with one or more family members to make diagnoses on all uninterviewed relatives. This difference (over ten standard errors) is due to the much higher rate of illness estimated for the uninterviewed relatives (28% compared to 14%). Analysis of the sources of insensitivity of the FH-RDC is used to explain the difference between observed and imputed diagnosis rates.     

Low levels and lack of predictors of somatotherapy and psychotherapy received by depressed patients

We examined the treatment of 338 patients with nonbipolar major depressive disorders during the first eight weeks after entry into the National Institute of Mental Health-Clinical Research Branch Collaborative Program on the Psychobiology of Depression: Clinical Study. Of the 250 entered as inpatients, 31% received either no antidepressant somatotherapy or very low or unsustained levels, and only 49% received at least 200 mg of imipramine hydrochloride (or its equivalent) for four consecutive weeks. Of these patients, 19% received less than 30 minutes of psychotherapy per week. Among the 88 who entered as outpatients, 29% received no antidepressant somatotherapy; another 24% received very low or unsustained levels; only 19% received at least 200 mg of imipramine hydrochloride or its equivalent for four consecutive weeks. Of these patients, 52% received less than 30 minutes of psychotherapy per week. Only a few clinical factors were found to be predictive of treatment intensity. Very large differences in the amount and type of treatment across the five collaborating university centers do not appear to be related to differences in patient characteristics.     

Hepatic amebic abscess: cholescintigraphic rim enhancement

Cholescintigrams of 17 amebic liver abscesses (ALAs) in 13 patients were studied retrospectively. Rim enhancement around a photopenic defect was seen in nine (53%) of 17 abscesses. Most of the ALAs were solitary, in the right lobe, and ovoid. All were contiguous with the liver capsule. Ultrasonograms, obtained in 11 of 13 patients, showed the ALAs to be predominantly hypoechoic, with low-level echoes on high-gain settings. No sonographic finding could be identified to correlate with rim enhancement. Cholescintigraphic rim enhancement may allow early diagnosis of ALA in patients with right-upper-quadrant pain, facilitating early institution of specific therapy while definitive serologic confirmation of ALA is awaited.