Improving preregistration training.
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Education, Medical, Graduate↗
Biomedical subjects
S Dowling
Publications and source records attributed to S Dowling.
Impaired motor function (clumsiness) in 5 year old children: correlation with neonatal ultrasound scans.
All 155 surviving children from a cohort of 200 very low birthweight infants originally studied in 1984-5 were traced. These infants had careful sequential ultrasound examinations in the neonatal period. The children were examined again at entry into school at 5 years of age. The test of motor impairment (TOMI) and the vocabulary subscale of the Wechsler preschool and primary scale of intelligence (WPPSI) were administered to 152 of the index cohort and 144 control children of the same age in the same class at school. Twelve of the cohort had cerebral palsy, but eight of these were in mainstream schools. The index group scored significantly higher on both the TOMI and the WPPSI subscale compared with the controls. The index cases were subdivided on the basis of their neonatal ultrasound scans into four groups: group 1, consistently normal; group 2, 'prolonged flare'; group 3, germinal matrix haemorrhage-intraventricular haemorrhage (GMH-IVH), without parenchymal haemorrhage, but no evidence of prolonged flare; and group 4, both GMH-IVH and prolonged flare. The group of index children with consistently normal ultrasound scans had a higher TOMI and lower WPPSI compared with their controls. There was a statistically significant increase in the TOMI subscore 1 (manual dexterity) in group 4 infants compared with group 1, but not differences between the other groups. Regression analysis suggests that neither prolonged flare nor GMH-IVH has an important individual contribution to the variation, but the low birth weight does have a significant relationship with motor impairment. It appears that relatively minor ultrasound appearances such as prolonged flare and GMH-IVH are associated with motor impairment (clumsiness) at 5 years, but this has a small effect compared with low birth weight.
Cerebral Palsy↗
Fluosol and hyperbaric oxygen as an adjunct to radiation therapy in the treatment of malignant gliomas: a pilot study.
Several clinical trials have been reported using Fluosol and oxygen breathing as an adjunct to radiation. Theoretical considerations and animal experiments, however, indicate that a combination of perfluorochemicals and hyperbaric oxygen (HBO) increases tumor oxygenation and radiation response to a greater extent than is seen either with a perfluorochemical and normobaric oxygen or with HBO alone. This is the first report of a pilot study of the use of Fluosol and HBO with radiation in humans. Twenty patients with anaplastic astrocytoma or glioblastoma multiforme were treated in a phase I trial of radiation with Fluosol and HBO at three atmospheres. Total Fluosol dose was escalated from 42 ml/kg in six courses to 80 ml/kg in four courses. Patients were irradiated in an HBO chamber with 600 cGy weekly fractions following Fluosol administration. Sixteen patients completed treatment; no interruption was necessitated by treatment toxicity. The addition of Fluosol/HBO did not increase the incidence of HBO related toxicities. No significant chronic toxicities were seen. This pilot study demonstrates that Fluosol and HBO can safely be used as an adjunct to radiation in the treatment of human tumors.
Adult↗
Junior doctors' confidence in their skill in minor surgery.
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Attitude of Health Personnel↗
Intraobserver and interobserver reliability in assessment of neonatal cranial ultrasounds.
Intraobserver and interobserver reliability in assessing neonatal cranial ultrasounds for periventricular-intraventricular hemorrhage (PVH-IVH) is not well studied; therefore, studies were designed to address this. For intraobserver reliability 180 cranial ultrasounds (360 hemispheres) were randomly selected from greater than 2000 ultrasounds and read twice by one radiologist in a blinded fashion. Ninety-eight percent were interpreted identically; of the 2% reinterpreted differently, all were initially abnormal but normal on the second reading. The least agreement occurred when interpreting ventricular size. Only four infants (1.1%) were placed in an unfavorable prognostic category (grades III and IV) on the first reading and a favorable prognostic category on the second interpretation (no bleed, grades I and II). To determine interobserver reliability, 20 sonograms were interpreted by eight independent observers representing five institutions. Using the multiple rater kappa kappa statistic, we determined interobserver agreement on overall impression (normal vs. abnormal), presence and extent of PVH-IVH (i.e. grade), presence of residual cyst, and ventricular dilatation. Greatest degree of agreement occurred when determining normal vs. abnormal, residual cyst, no bleed, and grades III and IV PVH-IVH. Poorest agreement occurred when reading grades I and II PVH-IVH and ventricular dilatation. After condensing interpretations of cranial ultrasounds into two prognostic categories, i.e. favorable (no bleed, grades I and II) and unfavorable (grades III and IV), there was excellent agreement among the observers.
Cerebral Hemorrhage↗
Pathologic stage I and II Hodgkin's disease. Long-term results at three Connecticut hospitals.
Three radiation therapy departments in Connecticut (Uncas on Thames Hospital, Norwich; Yale-New Haven Hospital, New Haven; and the Hospital of Saint Raphael, New Haven) have consistently used the strategy of staging laparotomy with splenectomy for clinical stage I and II Hodgkin's disease patients with primary radiation therapy as initial therapy for most pathologic stage (PS) I and II patients. From 1971 through 1986, 239 PS I and II patients were treated at these three institutions and 94% received radiation therapy alone as initial treatment. With a minimum follow-up time of one year and a maximum follow-up time of 18 years (mean: 7.3 years), only 19 (8%) of the 239 patients have ultimately died of Hodgkin's disease. Two factors were responsible for the low death rate due to Hodgkin's disease: 1) 176 patients (74%) went into complete remission following initial therapy and did not experience a relapse; and 2) 63 patients relapsed following initial therapy; however, subsequent salvage therapy was successful in 44 (70%) of these 63 patients. The overall 10-year and 18-year survival rates were 81% and 78%, respectively. Staging laparotomy with initial radiation therapy for most PS I and II patients remains an important and highly successful strategy for Hodgkin's disease.
Adolescent↗
Neonatal intracranial hemorrhage: I. Changing pattern in inborn low-birth-weight infants.
Many reports of the occurrence of periventricular-intraventricular hemorrhage (PVH-IVH) are biased by the inclusion of both inborn and outborn infants. To obviate this selection bias we examined a large inborn population of low-birth-weight infants to determine if the incidence of PVH-IVH changed over a 3-year interval from March, 1982 through February, 1985. Serial cranial ultrasonography was performed in 463 consecutive infants of birth weight less than or equal to 1500 g who survived for more than 8 h. The incidence of PVH-IVH decreased from 31.5% and 29.3% in years 1 and 2, respectively, to 23.7% in year 3 (P less than 0.05). The latter reflected a fall in the incidence of grades III and IV PVH-IVH, but no change in the incidence of grades I and II. This observation was not attributable to changes in mortality, the distribution of infants by birth weight and estimated gestational age in each year of the study, or infants excluded from the analysis. Contrary to most reports, 21.9% of all PVH-IVH during the 3 years were first diagnosed after 14 days postnatal age and were predominantly grade I. These results document not only a change in the epidemiology of PVH-IVH in an inborn population, but also the importance of serial cranial ultrasonography beyond the first week of life.
Birth Weight↗
Neonatal intracranial hemorrhage: II. Risk factor analysis in an inborn population.
The ability to predict the occurrence of neonatal periventricular-intraventricular hemorrhage (PVH-IVH) would be useful in the design of clinical trials to prevent its occurrence. Therefore, data were collected from 463 consecutive infants less than or equal to 1500 g birth weight delivered between March 1, 1982 and February 28, 1985. This large population made it feasible to divide the infants into two groups, using one group to develop a model predictive of ICH and the second group to test the validity of the model. Infants were randomly grouped by sex, race, gestational age, birth weight, month of birth, mortality, and incidence and grade of worst PVH-IVH. In Group A (n = 232), respiratory distress syndrome, ventilator therapy, PaCO2 greater than or equal to 60 mmHg, PO2 less than or equal to 40 mmHg greater than or equal to 2 h, lower 1- and 5-min Apgar scores, lower pediatric estimation of gestational age, and pneumothorax were significantly associated with PVH-IVH by univariant analyses (chi 2, P less than 0.03). Multivariant discriminant analysis performed on Group A revealed that pneumothorax, cesarean section, PaCO2, and ventilator therapy were most predictive of PVH-IVH, but sensitivity was 55% and specificity 78%. Applying the model to Group B, sensitivity decreased to 21% while specificity rose to 93%. Logistic regression, which takes into account non-normally distributed variables, did not improve predictability.(ABSTRACT TRUNCATED AT 250 WORDS)
Apgar Score↗
Fantasy formation: a child analyst's perspective.
Unconscious fantasy is the principal unit of psychoanalytic investigation. Though individual fantasies, either conscious or unconscious, may emphasize drive, defense, or superego interests, all fantasy life develops from a limited number of themes; these themes concern drive-related issues, experiences of helplessness, or combinations of both. Fantasy formation and fantasy content undergo developmental change. Sensorimotor, behavioral memories occur prior to fantasy and are influential in determining repetitive behavioral enactments. The complexities of infant behavior do not require the postulation of fantasy or representational memory. A complex, innate, instinctual organization of the newborn, similar in many respects to that of other newborn mammals, and distinct from the psychological organization of the older infant, is suggested as an explanation of these phenomena.
Adolescent↗
Nutrition in the management of HIV antibody positive patients: a longitudinal study of dietetic out-patient advice.
The efficacy of a dietetic service was evaluated in an AIDS clinic; 17 asymptomatic (CDC II) and 17 symptomatic (CDC IV) patients participated in a 12 week evaluation of out-patient dietetic advice. The symptomatic group, classified as CDC stage IV according to the Centre for Disease Control classification, were significantly lighter (P less than 0.05) and had significantly lower values for usual weight, current body mass index, mid-upper arm and mid-arm muscle circumferences and triceps and subscapular skinfold thicknesses (P less than 0.05) at the outset of the study. There were no significant differences in nutrient intakes between the two groups. After 12 weeks of dietetic intervention which included personalised advice, prescription of food supplements and the provision of a special food allowance as social welfare payments for the unemployed, there were significant increases in the intakes of most nutrients, the effect being greater with the symptomatic CDC IV group. It is concluded that dietetic intervention has a significant role to play in the management of HIV antibody positive patients.
Adult↗
The relationship between cluster and liquid simplification and sentence length, age, and IQ in Down's syndrome children.
Twenty-two Down's syndrome children who were 6 years, 6 months to 12 years, 7 months of age were tested to assess the relationships among cluster reduction, liquid simplification and sentence length, age, and IQ. Sentence length was found to be the primary predictor of cluster reduction and liquid simplification in the articulatory productions of Down's syndrome children. The liquid /r/ was generally more difficult than the liquid /l/ for the subjects.
Age Factors↗
An analysis of potential biases in the loss of indigent infants to follow-up.
Loss to follow-up is a major problem in indigent inner-city populations. We evaluated a large, well-described, inborn indigent population of high-risk infants (HRI) and control infants (CI) to assess possible selection biases in loss to follow-up at one year adjusted age. Serial clinic visits, phone calls, and letters and payment of $20.00 for attending at 1 year was used to minimize patient loss. Yet, the 1 year loss rate was high, and among HRI, greater for ventilator-treated infants greater than 1500 g birthweight (71/114; 62%) than for ventilator-treated very-low-birthweight (VLBW; less than 1500 g) infants (39/108; 36%) or non-ventilated VLBW infants (62/145; 43%) (P less than 0.05). Multivariate analyses indicated that those lost to follow-up were at no greater risk of a poor outcome on the basis of prenatal and perinatal medical and socioeconomic findings than were those in the same risk group (HRI or CI) or subgroup of HRI who were examined at 1 year. In a review of hospital records, similar rates of hospitalization and neurologic problems during infancy were identified for HRI examined and HRI lost to follow-up. The identification of such morbidity during infancy may be less complete for HRI lost to follow-up than for those examined. Thus, the high frequency of deficits observed in follow-up evaluation of indigent HRI is unlikely to result from loss of unaffected infants.
Child Health Services↗
Disappointing follow-up findings for indigent high-risk newborns.
Indigent populations have received little attention in neonatal follow-up studies. We conducted "blinded" evaluations one year past term for 204 indigent high-risk infants who were ventilator treated or had a very low birth weight (VLBW) (less than or equal to 1500 g) and 85 healthy term controls from families similar to those of the high-risk infants. Marked developmental delay (Bayley Mental Developmental Index, less than 70) or gross motor abnormality occurred in 2% of controls, 27% of VLBW infants, 33% of ventilator-treated infants, and 39% of ventilator-treated VLBW infants. Despite considerable effort to prevent attrition, 43% of high-risk survivors were unavailable for follow-up at the one-year visit. Even if all of these infants were assumed to be normal, the incidence of developmental delay exceeded that in 11 of 12 recent studies. Indigent high-risk infants deserve considerable follow-up attention because of their high rate of attrition and developmental delay.
Anthropometry↗
Teaching clinic conferences: perceptions of supervisor and peer behavior.
Perceptions of supervisor and peer behavior during teaching clinic conferences, a group supervisory approach, were assessed. Four groups of graduate students participated in a total of 19 teaching clinics. Following each conference, they completed two Individual Conference Rating Scales to describe the supervisor and peer during the interaction. Peer behavior differed from that of supervisors. Differences were also found between supervisors and among groups of students participating in the conferences. A participant's role had no impact on the participants' perceptions of either the peers or supervisors. Variations in perceptions were noted as the number of clinics per group increased.
Education, Graduate↗
The teaching clinic: a supervisory alternative.
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Peer Group↗
Seven infants with esophageal atresia. A developmental study.
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Child, Preschool↗
Family studies of patients with reduced ristocetin aggregation and abnormalities of factor VIII and/or platelet function.
Factor VIII procoagulant activity (VIIIc), antigen (vWa), mobility of the antigen on two dimensional immunoelectrophoresis and platelet function were studied in 9 families with reduced ristocetin induced platelet aggregation rate (RIPA) and/or deficiency of plasma factor(s) required for ristocetin aggregation of washed normal platelets (vWf). the families could be subdivided into 4 groups. Group I showed dominant inheritance and reduced levels of VIIIc and vWa characteristic of typical von Willebrand's disease. All patients had reduced vWf and in 7 of 10 RIPA was reduced. Group II showed normal levels of VIIIc but reduced vWa. All showed reduced vWf but RIPA was reduced in one patient only. There was a good correlation between vWf and vWa and VIIIc in both groups. The bleeding time correlated with vWf in group I but not group II. Group III showed normal or nearly normal VIIIc and vWa but there was an increased mobility of vWa compared to normals and to groups I and II. RIPA was markedly reduced as was the vWf in one patient. Group IV is represented by one child with a strong family history of bleeding, who had reduced RIPA and defective platelet release reaction. The vWf in this child was normal and the ratio between VIIIc and vWa was similar to that seen in carriers of haemophilia. This spectrum of abnormalities of ristocetin aggregation justifies the use of the term 'von Willebrand's syndrome'.
Animals↗