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Identification and assessment of students with disabilities.

Students with disabilities or suspected disabilities are evaluated by schools to determine whether they are eligible for special education services and, if eligible, to determine what services will be provided. In many states, the results of this evaluation also affect how much funding assistance the school will receive to meet the students' special needs. Special education classification is not uniform across states or regions. Students with identical characteristics can be diagnosed as disabled in one state but not in another and may be reclassified when they move across state or school district lines. Most disabilities with a clear medical basis are recognized by the child's physician or parents soon after birth or during the preschool years. In contrast, the majority of students with disabilities are initially referred for evaluation by their classroom teacher (or parents) because of severe and chronic achievement or behavioral problems. There is evidence that the prevalence of some disabilities varies by age, the high-incidence disabilities such as learning disabilities and speech-language disabilities occur primarily at the mild level, the mild disabilities exist on broad continua in which there are no clear demarcations between those who have and those who do not have the disability, and even "mild" disabilities may constitute formidable barriers to academic progress and significantly limit career opportunities. Problems with the current classification system include stigma to the child, low reliability, poor correlation between categorization and treatment, obsolete assumptions still in use in treatment, and disproportionate representation of minority students. Both African-American and Hispanic students are disproportionately represented in special education but in opposite directions. The disproportionately high number of African Americans in special education reflects the fact that more African-American students than white students are diagnosed with mild mental retardation. Though poverty, cultural bias, and inherent differences have been suggested as reasons for this disproportionate representation, there are no compelling data that fully explain the phenomenon. In most states, classification of a student as disabled leads to increased funding from the state to the school district. This article suggests a revised funding system that weights four factors (number of deficits, degree of discrepancy, complexity of intervention, and intensity of intervention) in a regression equation that would yield a total amount of dollars available to support the special education of a particular student.

Adolescent

Pathogenesis, clinical features and management of hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic skin condition involving the apocrine glandular zones. Affected patients may present with acute abscesses, but the condition often progresses to a chronic state with persistent pain, sepsis, sinus tract and fistula formation, purulent discharge and dermal scarring. Treatment of patients with severe disease can be difficult and may require complex surgical intervention. This review encompasses the pathogenesis, clinical manifestations and management options for patients with hidradenitis suppurativa.

Axilla

Using airway pressure.

This is the third part in the series Care is Critical which looks at the more complex technological interventions nurses may now have to deal with on general wards or in the community. This article looks at continuous positive airway pressure, an oxygen delivery system which can relieve significant respiratory distress in some cases. The first two were published on June 25.

Critical Care

Cardiovascular assessment.

This is the fourth part in the series Care is Critical, which looks at the theory and practice of the more complex technological interventions nurses may now have to manage on general wards or in the community. This article is the first of two looking at cardiovascular assessment. The next part of this series will appear on September 24.

Aged

Fluoroscopically guided suprapubic cystostomy in complex urologic cases.

PURPOSE: To evaluate the efficacy of percutaneous suprapubic cystostomies performed by the interventional radiologist for complex urologic cases. MATERIALS AND METHODS: A retrospective analysis was done of the 25 cases referred to the radiology department for suprapubic cystostomies. The patients were referred because of unsuccessful placement or malposition of a suprapubic cystostomy tube. The procedure was performed with the Seldinger technique by using a 21-gauge needle for initial antegrade puncture and subsequent tract dilation and placement of 10-24-F catheters. RESULTS: In 24 of 25 cases (96%) the suprapubic cystostomy was successfully performed. After suprapubic cystostomy, eight patients (32%) underwent additional ancillary procedures by urologists through the suprapubic tract. The only major complication was perivesical fluid collection in one patient (4%), which was subsequently drained. Seventeen patients (68%) had transient hematuria. CONCLUSION: Percutaneous suprapubic cystostomy performed under fluoroscopic control is an effective and safe procedure ideally suited for the interventional radiologist, especially in complex urologic cases.

Adolescent

Relative role of ambulatory and residential rehabilitation.

Cardiac rehabilitation, derived from the concept of early mobilization after an acute cardiac event, seems destined to assume an important role in the approach to patients affected by chronic heart disease (ischaemic heart disease, valvular and congenital diseases, heart transplant, chronic heart failure, etc.). To respond to individual clinical needs, rehabilitative intervention should be organized either at an outpatient level or by combining outpatient and inpatient activities. Three different levels of intervention, of increasing complexity and specialization, are foreseen. First-level interventions are to be performed exclusively at outpatient level and directed mainly towards long-term care of stable chronic patients in order to keep them at the highest level of autosufficiency possible and to prevent acute events. Second-level interventions include the combination of outpatient and inpatient rehabilitative activity, based on an accurate prognostic stratification intended to reduce the consequences of the handicaps which the individual reports after an acute event. Third-level interventions include services provided in highly specialized centres; they should function at both inpatient and outpatient levels, and should be instituted in close collaboration with cardiosurgical departments that are particularly oriented towards transplant activity.

Ambulatory Care

The APSAC interventional mortality study (AIMS) trial: mortality data.

The anistreplase (anisoylated plasminogen streptokinase activator complex or APSAC) intervention mortality study was designed as a double-blind, placebo-controlled study to test the effectiveness of anistreplase, 30 U administered intravenously within the first 6 hours of acute myocardial infarction. The primary endpoint of the study was mortality of all causes at 30 days and 1 year. Within 30 days, there were 77 deaths with placebo (17.8%) and 40 deaths (6.5%) with anistreplase, an odds reduction of 50.5% (p = 0.0006). By the end of one year, there had been a total of 113 deaths (17.8%) with placebo and 69 deaths (11.1%) with anistreplase, an odds reduction of 42.7% (p = 0.0007).

Acute Disease

Combined radiologic and retrograde endoscopic and biliary interventions.

Methods of treating complex biliary duct problems by a team composed of an endoscopist and interventional radiologist are described. These procedures are of two types: Those in which all manipulations are performed through the endoscope and those in which an antegrade transhepatic and a retrograde endoscopic approach are combined.

Bile Duct Diseases

The beta-adrenergic receptor-adenylate cyclase complex as a target for therapeutic intervention in heart failure.

In the human heart the beta-adrenergic pathways are the primary means of increasing cardiac performance in response to acute or chronic stress. Control of beta pathway function is achieved by changes in the receptors themselves, and to a lesser degree by adjustments in the inhibitory G protein (Gi). In heart failure myocardial beta-receptor function is substantially reduced, but the beta-receptor pathways are so powerful that they remain capable of supporting inotropic function. Certain therapeutic interventions that improve exercise performance in heart failure can partially restore beta-receptor pathway function to normal; these interventions include beta-blocker therapy and treatment with angiotensin converting enzyme inhibitors. Other types of therapy, such as chronic administration of beta-adrenergic agonists, may produce undesirable effects by increasing beta-receptor subsensitivity; however, the effects of beta-agonists on beta-receptor function are somewhat unpredictable and certain beta-agonists do not appear to produce much desensitization. Finally, the failing human heart is in effect partially denervated due to depletion of neuronal norepinephrine, and consequently in advanced heart failure beta-agonists that possess an indirect component of action will be less effective than exclusively direct-acting agents. These observations indicate that the baseline status and the intervention-associated behaviour of the human myocardial beta-adrenergic receptor systems need to be considered in developing therapeutic strategies in congestive heart failure.

Adenylyl Cyclases

[Immunopathology of arterial diseases (author's transl)].

The clinical manifestations of necrotizing angeiitis are of many types (periarteritis nodosa, Wegener's granulomatosis, hypersensitivity, vasculitis...). Their immunological origin is strongly suggested by their analogy with the experimental models of immune complex diseases, and the presence of many immunological anomalies indicating the presence and intervention of these complexes. Several arguments strongly suggest that immunological factors may be also implicated in the pathogenesis of arterial hypertension and arteriosclerosis.

Antigen-Antibody Complex

Regulation of collagenase. Therapeutic considerations.

Why the cornea ulcerates, in the sense of what goes awry, may be related to the trapping of wound healing in a phase of proteolytic debridement related to a persistent epithelial defect. The initial avascularity of the cornea makes it particularly vulnerable to proteolytic damage. Studies on the biochemistry and cell biology of corneal ulceration have indicated that sequential interactions occur which result in the generation of collagenase activity and the development of ulceration. It is likely that the interactions are susceptible to intervention; and it is thought that eventual, successful treatment of corneal ulceration will require a complex therapy, with interventions at multiple sites of regulation.

Animals

Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications.

BACKGROUND: Low adherence of patients to prescribed, self-administered medical interventions is ubiquitous. Low adherence limits the benefits of current medical care. Efforts to assist patients to follow treatments might improve the efficiency of care and substantially enhance benefits. Our objective was to summarise the results of randomised controlled trials (RCTs) of interventions to help patients follow prescriptions for medications. METHODS: A previous systematic review was updated through computerised searches in Medline, International Pharmaceutical Abstracts, Psychinfo, and HSTAR online databases; bibliographies in articles on patient adherence; articles in the reviewers' personal collections; and contact with authors. Articles were judged of interest if they reported original data concerning an unconfounded RCT of an intervention to improve adherence with prescribed medications, with one or more measure of medication adherence, one or more measure of treatment outcome, at least 80% follow-up of each group studied, and, for long-term treatments, at least 6 months of follow-up for studies with positive initial findings. Information on study design features, interventions and controls, and findings were extracted by one reviewer (RK) and checked by the other two reviewers. FINDINGS: 1,553 relevant citations and abstracts were screened, 252 full text articles were reviewed in detail, and 13 RCTs met all criteria. The studies were too disparate in clinical problems, adherence interventions, measures and reporting of adherence, and the clinical outcomes studied to warrant meta-analysis. Seven of 15 interventions were associated with improvements in adherence and six interventions led to improvements in treatment outcomes. For short-term treatments, one study showed an effect on adherence and outcome of counselling and written information. The interventions that were effective for long-term care were complex, including various combinations of more convenient care, information, counselling, reminders, self-monitoring, reinforcement, family therapy, and other forms of additional supervision or attention. Even the most effective interventions did not lead to substantial improvements in adherence. INTERPRETATION: Although adherence and treatment outcomes can be improved by certain-usually complex-interventions, full benefits of medications cannot be realised at currently achievable levels of adherence. It is time that additional efforts be directed towards developing and testing innovative approaches to assist patients to follow treatment prescriptions.

Drug Therapy

[Relapse symptom complex in rectal cancer after radical surgical interventions].

The analysis of 78 questionnaires of patients with recurrence of rectal cancer was performed which revealed this complication of surgery to occur in 60% of cases within a year after operation. Recurrences of the rectum cancer show a characteristic complex of symptoms with a certain structure of painful sensations as a central criterion.

Anal Canal

Fractal analysis of role of smooth muscle Ca2+ fluxes in genesis of chaotic arterial pressure oscillations.

We have investigated the role of vascular smooth muscle Ca2+ fluxes in the genesis of chaotic pressure oscillations induced by histamine in isolated resistance arteries from the rabbit ear. The responses exhibited distinct "fast" and "slow" components, with periods of 5-20 s and 1-5 min, respectively, which could be dissociated pharmacologically. The fast subsystem involved ion movements at the cell membrane and was inhibited by both low (< 2 mM) and high (> 5 mM) extracellular Ca2+ concentration ([Ca2+]o) by verapamil (which inhibits voltage-dependent Ca2+ influx) and by charybdotoxin (ChTX) and apamin (which block Ca(2+)-activated K+ channels). In contrast, the slow subsystem was intracellular and was selectively attenuated by ryanodine, which inhibits Ca(2+)-induced Ca2+ release from sarcoplasmic reticulum. The effects of these interventions on the complexity of the responses were quantified by calculating their fractal dimension, a parameter that estimates the minimum number of independent variables contributing to an irregular time series. Its mean value was generally > 2 under control conditions but decreased to < 2 in a concentration-dependent fashion in the presence of verapamil, ChTX, apamin, or ryanodine and when [Ca2+]o was outside the range of 2-3 mM. Each intervention thus removed one dimension of complexity from the mechanisms generating the rhythmic activity. We conclude that the interaction of a fast membrane oscillator, which involves Ca2+ influx, Ca(2+)-activated K+ efflux, and therefore presumably changes in membrane potential, and a slow intracellular oscillator involving Ca2+ sequestration and release from stores is responsible for vascular chaos in our model. The coupling between these subsystems is likely to be mediated by cytosolic [Ca2+].

Animals

Genetic screening for colorectal cancer and intervention.

There is a complex interaction between environmental/dietary factors and genetics underlying the pathogenesis of colon carcinogenesis. Little data exist concerning the impact of diet on the phenotypic expression of genetically linked colon cancer. As a result, it has been difficult to develop rationally designed dietary intervention studies in first-degree relatives of patients with established familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC) and other familial colon cancer syndromes. Only 2 double-blinded, placebo-controlled trials have been published concerning the use of preventive strategies in patients with genetically inherited colorectal cancer syndromes, both in patients with FAP. One study evaluated the effects of vitamin C plus vitamin E with or without a high-dose wheat bran fiber supplement on the recurrence of rectal adenomas. Over a 48-month intervention period, only the wheat bran fiber intervention significantly reduced polyp growth. A second study reported that intervention with the NSAID sulindac for 9 months in young patients with FAP resulted in a significant reduction in both polyp number and size in the rectosigmoid colon. All of the large-scale (i.e., >500 randomized participants) phase III nutrient or chemopreventive agent intervention studies thus far have targeted participants with a history of non-familial, sporadic colorectal adenomas. Current clinical adenoma trials do not measure whether the regimen being tested can prevent genotoxic events occurring in early stages of abnormal cell development that contribute to the eventual formation of adenomas nor whether the agent(s) can inhibit events occurring during the progression of adenomas to carcinomas. Therefore, future clinical trial designs may have to consider (i) lengthening the clinical trial period before adenomas develop, (ii) testing at early patient ages and/or (iii) measuring the growth of adenomas as they progress to carcinomas.

Clinical Trials as Topic

Vector population responses to control interventions.

In 1981, Kenyan authorities attempted eradication of tsetse (Glossina pallidipes) from the Lambwe valley, by sequential aerial spraying of endosulfan. Fly populations were reduced by over 99.9% in the main habitats, but recovered to their original levels within one year. In 1986, an Argentine research team attempted local elimination of domestic Triatominae (Triatoma infestans) in an area of Santiago del Estero. House infestation rates were reduced to an apparent zero, but recovered to pre-control levels in two years. In Sri Lanka, a combination of mosquito control with active case detection and treatment reduced malaria incidence to just 17 cases in 1964. Interruption of the programme then saw case incidence return to over 500,000 by 1969. These three examples-from African trypanosomiasis, South American Chagas disease and malaria-all illustrate the same process. Vector populations, infestation rates, and rates of disease transmission, can be reduced. The real problem is not in achieving the initial reduction, but in subsequently either driving the disease to extinction or maintaining it below acceptable levels. And this problem takes us beyond the simple analysis of interventions, into the complex realms of population behaviour set in its political, social and economic context. It seems that we have been too rarely concerned to plan and implement the long term surveillance and selective interventions that are required to translate initial gains into real success. In biological terms, we tend to ignore the complexity and robustness of vector populations and disease transmission cycles, especially their varied capacity to recover from interference. Moreover, in socio-political terms, a reduced problem-even one representing potential for future catastrophe-tends to claim less priority than present problems, even though premature redeployment of resources may abnegate gains already achieved. The problem is strongly compounded by methods of economic analysis where the benefits of avoiding future problems are strongly discounted in favour of short-term temporary gains. This paper seeks to open discussion on these long-term planning issues.

Animals