Early and intensive Motor Training for people with spinal cord injuries (the SCI-MT Trial): description of the intervention.

STUDY DESIGN: Descriptive. OBJECTIVES: The primary objective is to describe the intervention that will be provided in a large multi-centre randomised controlled trial titled: Early and Intensive Motor Training for people with Spinal Cord Injuries (the SCI-MT Trial). The secondary objective is to describe the strategies that will be used to operationalise and standardise the Motor Training provided to participants while keeping the intervention person-centred. METHODS: The paper focuses on the rationale and principles of Motor Training for people with spinal cord injuries (SCI). The description of the intervention is based on the Template for Intervention Description and Replication (TIDieR) checklist. Specifically, it addresses the following 6 criteria of the TIDieR checklist: why the effectiveness of Motor Training is being examined; what, how, where and when the Motor Training will be administered; and how much Motor Training will be provided. RESULTS: A detailed intervention manual has been developed to help standardise the delivery of the intervention. CONCLUSIONS: This paper describes the details of a complex intervention administered as part of a large randomised controlled trial. It will facilitate the subsequent interpretation of the trial results and enable the intervention to be reproduced in clinical practice and future trials.

The transport of group 2 capsular polysaccharides across the periplasmic space in Escherichia coli. Roles for the KpsE and KpsD proteins.

The cell surface expression of group 2 capsular polysaccharides involves the translocation of the polysaccharide from its site of synthesis on the inner face of the cytoplasmic membrane onto the cell surface. The transport process is independent of the repeat structure of the polysaccharide, and translocation across the periplasm requires the cytoplasmic membrane-anchored protein KpsE and the periplasmic protein KpsD. In this paper we establish the topology of the KpsE protein and demonstrate that the C terminus interacts with the periplasmic face of the cytoplasmic membrane. By chemical cross-linking we show that KpsE is likely to exist as a dimer and that dimerization is independent of the other Kps proteins or the synthesis of capsular polysaccharide. No interaction between KpsD and KpsE could be demonstrated by chemical cross-linking, although in the presence of both KpsE and Lpp, KpsD could be cross-linked to a 7-kDa protein of unknown identity. In addition, we demonstrate that KpsD is present not only within the periplasm but is also in both the cytoplasmic and outer membrane fractions and that the correct membrane association of KpsD was dependent on KpsE, Lpp, and the secreted polysaccharide molecule. Both KpsD and KpsE showed increased proteinase K sensitivity in the different mutant backgrounds, reflecting conformational changes in the KpsD and KpsE proteins as a result of the disruption of the transport process. Collectively the data suggest that the trans-periplasmic export involves KpsD acting as the link between the cytoplasmic membrane transporter and the outer membrane with KpsE acting to facilitate this transport process.

Confidential billing accounts for adolescents in private practice.

The purpose of this study was to determine how individual confidential billing accounts for adolescents in private practice would be received, and to assess the impact of these accounts on practice reimbursement. Adolescents wishing to keep confidential any part of the charges for an office visit were offered individual billing accounts. Enrollees agreed to pay whenever and whatever they could. One attempt was made to contact nonpayers at least 3 months after starting their accounts. The mean charge for 40 confidential accounts was $42 (total charges $1489) and all of the charges were for laboratory testing. Participants reimbursed 38% of the total charged ($565/$1489). Confidential accounts were well-received by study participants and may improve access to confidential care.

Sources of stress, burnout and intention to terminate among rugby union referees.

We examined sources of stress, burnout and intention to terminate among rugby union referees. Questionnaires were returned by 682 of 1175 referees (58%) from Wales, Scotland and England. Exploratory and confirmatory factor analyses revealed four correlated sources of stress factors (performance concerns, time pressure, interpersonal conflict and fear of physical harm), which accounted for 49.6% of the variance. Referees believed the first three factors to be mildly related to their stress. They believed fear of physical harm to be unrelated to their stress. A structural model hypothesizing that time pressure and interpersonal conflict predict burnout, and that age and burnout predict intention to terminate refereeing, fit the observed data. The goodness-of-fit index for this model was 0.96. Our results and those of other studies indicate that interpersonal conflict and time pressure are common sources of stress for sport officials and are frequently related to their burnout experiences. Also, age and burnout are frequently, although only marginally, related to intention to terminate.

Simulating the effect of cochlear-implant electrode insertion depth on speech understanding.

Normally hearing listeners were presented with vowels, consonants, and sentences for identification through an acoustic simulation of a five-channel cochlear implant with electrodes separated by 4 mm (as in the Ineraid implant). The aim of the experiment was to simulate the effect of depth of electrode insertion on identification accuracy. Insertion depth was simulated by outputting sine waves from each channel of the processor at a frequency determined by the cochlear place of electrodes inserted 22-25 mm into the cochlea. The results indicate that simulated insertion depth had a significant effect on performance. Performance at 22- and 23-mm simulated insertion depths was always poorer than normal, and performance at 25 mm simulated insertion depth was, most generally, the same as normal. It is inferred from these results that, if insertion depth could be unconfounded from other coexisting factors in implant patients, then insertion depth would be found to affect speech identification performance significantly.

Ratings of stress by rugby referees.

682 rugby referees from Wales, Scotland, and England rated their stress associated with refereeing on a 3-item scale. Mean ratings for the total sample and each group were between "very little" and "a moderate amount." Results support earlier studies, suggesting that most sport officials do not experience much stress while officiating.

Clinician agreement on physical findings in child sexual abuse cases.

OBJECTIVE: To measure agreement among experienced clinicians regarding the interpretation of physical findings in child sexual abuse cases and to determine whether knowledge of clinical history affects the interpretation of the physical findings. DESIGN: Experienced clinicians rated colposcopic photographs on a scale of 1 to 5 with 1 being normal and 5 being clear evidence of penetrating injury. To answer an additional study question of whether clinical history affected interpretation, 4 clinicians rated 69 cases in which they were blinded to the patients' histories and 70 cases in which the patients' histories were available. The other 3 clinicians then rated the same cases with the presence or absence of history reversed. SETTING: All clinicians involved perform child sexual abuse examinations at tertiary care centers. PATIENTS: A total of 139 girls with Tanner stage 1 or 2 genitalia who were referred to a general pediatric clinic at an academic medical center for examination of possible sexual abuse. RESULTS: Half of the photographs were interpreted as indicating little or no evidence of abuse. Of those photographic sets that both readers could interpret, 39% were in perfect agreement and 77% disagreed by 1 category or less. Perfect agreement across all possible pairs of readers was 34.5%. Agreement was better when the patient's clinical history was unknown (29.3% vs 38.9%, P = .005). The kappa, a measure of interrater reliability, indicated poor agreement among clinicians. The combined kappa for the first group of clinicians was 0.22 without knowledge of clinical history and 0.11 with knowledge of clinical history. For the second group of clinicians, the kappa was 0.31 without knowledge of clinical history and 0.15 with knowledge of clinical history. The overall kappa across all 7 clinicians disregarding clinical history was 0.20. Agreement was best for categories 1 (normal, kappa = 0.28) and 5 (clear evidence of a penetrating injury, kappa = 0.39). CONCLUSIONS: Clinicians educated and experienced in assessing child sexual abuse do not agree perfectly on the interpretation of photographs of genital findings in girls with Tanner stage 1 or 2 genitalia. Clinicians agree less when a patient's clinical history is available. Efforts should be directed at standardizing physical findings and avoiding overemphasis on physical findings in child sexual abuse cases.

Masking by modulated and unmodulated noise: effects of bandwidth, modulation rate, signal frequency, and masker level.

The threshold for a sinusoidal signal masked by a band of noise is often times lower when the masking noise is modulated than when it is unmodulated. The difference in masked thresholds is referred to as the modulated-unmodulated difference, or MUD. These present experiments examined the effects of masker bandwidth, masker rate, and masker level on the MUD at several different signal frequencies. The MUD generally increased with increasing masker bandwidth; for masker bandwidths wider than a critical band (or an equivalent rectangular bandwidth-ERB), the results may be influenced by across-channel processes underlying comodulation masking release. The MUD for an ERB masker (MUDERB) was influenced less by masker rate than was the MUD for a broadband (BB) masker (MUDBB). The MUDERB and especially the MUDBB increased significantly with increasing masker level when the modulated masker was modulated at a depth (m) of 1.0, but not when it was modulated at a depth of 0.75. These results have significant implications for extending the MUD paradigm to hearing-impaired subjects. Finally, the MUDERB and the MUDBB increased with increasing signal frequency. This effect for the ERB masker is largely (if not completely) due to the wider absolute bandwidths at higher frequencies. The effect with the BB masker may be influenced by differences in the magnitude of suppression across frequency.

Speech intelligibility as a function of the number of channels of stimulation for signal processors using sine-wave and noise-band outputs.

Vowels, consonants, and sentences were processed through software emulations of cochlear-implant signal processors with 2-9 output channels. The signals were then presented, as either the sum of sine waves at the center of the channels or as the sum of noise bands the width of the channels, to normal-hearing listeners for identification. The results indicate, as previous investigations have suggested, that high levels of speech understanding can be obtained using signal processors with a small number of channels. The number of channels needed for high levels of performance varied with the nature of the test material. For the most difficult material--vowels produced by men, women, and girls--no statistically significant differences in performance were observed when the number of channels was increased beyond 8. For the least difficult material--sentences--no statistically significant differences in performance were observed when the number of channels was increased beyond 5. The nature of the output signal, noise bands or sine waves, made only a small difference in performance. The mechanism mediating the high levels of speech recognition achieved with only few channels of stimulation may be the same one that mediates the recognition of signals produced by speakers with a high fundamental frequency, i.e., the levels of adjacent channels are used to determine the frequency of the input signal. The results of an experiment in which frequency information was altered but temporal information was not altered indicates that vowel recognition is based on information in the frequency domain even when the number of channels of stimulation is small.

Magnitude of stress reported by basketball referees.

723 basketball referees responded to a survey that assessed stress related to officiating. Mean reported ratings were between "very little" and "moderate amount"; only 4% reported high stress. Results are consistent with other accounts, suggesting that most sport officials experience low occupational stress.

Are adolescents who report prior sexual abuse at higher risk for pregnancy?

Adolescents who report prior sexual abuse are at increased risk for adolescent pregnancy. This may result from earlier, more frequent, less well-protected sexual activity or from a greater desire to conceive. To determine the relative contribution of these two possible explanations to the reported association between sexual abuse and adolescent pregnancy, we studied the reproductive and sexual histories of 200 sexually active 13-18 year old females in relation to self-reported sexual abuse. Anonymous questionnaires revealed that 40 (20%) of the 200 subjects reported sexual abuse. Analyses revealed no group differences in the median age of first voluntary intercourse, the frequency of sexual intercourse, or the consistency of birth control use. Compared to their nonabused peers, however, teenagers reporting abuse were more likely to be trying to conceive (35% vs. 14% p < .01), to have boyfriends pressuring them to conceive (76% vs. 44% p < .01), and to have fears about infertility (38% vs. 16% p < .01). Our findings suggest that childhood sexual abuse may increase the risk of adolescent pregnancy by fostering the desire to conceive. Further study is needed to determine why a disproportionate number of sexually abused adolescents desire pregnancy. The efficacy of adolescent pregnancy prevention programs may be improved by identifying previously abused adolescents and by designing educational interventions that specifically address their desire to conceive.

PIP: Female adolescents who report prior sexual abuse are at increased risk for adolescent pregnancy. Such pregnancy may result from earlier, more frequent, less well-protected sexual activity or from a greater desire to conceive. The authors studied the reproductive and sexual histories of 200 sexually active 13-18 year old females in relation to self-reported sexual abuse to determine the relative contribution of these two possible explanations to the association between sexual abuse and adolescent pregnancy. 20% of the participants reported being sexually abused. There were, however, no differences found between the groups in the median age of first voluntary intercourse, the frequency of sexual intercourse, or the consistency of birth control use. Compared to their nonabused peers, however, teenagers reporting abuse were more likely to be trying to conceive, to have boyfriends pressuring them to conceive, and to have fears about infertility. These findings therefore suggest that childhood sexual abuse may increase the risk of adolescent pregnancy by fostering the desire to conceive. Further study is needed to determine why a disproportionate number of sexually abused adolescents desire pregnancy.

Parents' knowledge of the purposes and content of preparticipation physical examinations.

OBJECTIVES: To determine whether parents of student athletes plan to use the preparticipation physical examination (PPE) as their student athlete's only annual health evaluation, to identify factors associated with this decision, and to assess their knowledge about the objectives of PPEs and more comprehensive examinations. DESIGN: Survey. SETTING: General community, school-sponsored PPEs. PARTICIPANTS: A convenience sample of parents or guardians of high school student athletes who obtained a school-sponsored, multiple-station format PPE were surveyed by using an anonymous paper-and-pencil questionnaire. Questionnaires were completed by the parents of 381 of 763 student athletes who obtained PPEs (participation rate, 49.9%). RESULTS: Thirty percent of the parents in this sample planned to use the PPE as their student athlete's only contact with a health care provider. Parents whose adolescent's health insurance provided for comprehensive health assessments were more likely than those without this benefit to plan a comprehensive care evaluation (75% vs 60%, respectively) (P = .01 by chi 2 analysis). In addition to addressing problems that might affect sports participation, parents thought that the PPE visit should evaluate medical problems that are unrelated to athletics (34%), perform health screening procedures (22%), assess social or behavioral issues (16%), and provide immunizations (7%). CONCLUSIONS: Many parents plan to use the PPE as their student athlete's only scheduled contact with a health care provider; this decision may be influenced by factors that are related to access to health care and misperceptions with regard to the mission of these specialized examinations. For these adolescents, important medical, social, and behavioral needs may not be met. Consideration should be given to including elements of the PPE in health assessments that are performed by individual clinicians or expanding the scope of large-group, multiple-station format PPEs.

Compliance with return appointments for reproductive health care among adolescent Norplant users.

PURPOSE: Norplant's long duration of action may result in users being less motivated than non-users to return for reproductive health care appointments. This study determined compliance with scheduled return appointments among adolescents using Norplant and those using other methods of contraception. METHODS: We retrospectively reviewed the records of all teenagers (age < or = 18 years) who received Norplant between June 1991 and August 1993, as well as those of a comparison group of adolescents, matched for age and race, using other methods of contraception. Subjects receiving Norplant were given appointments for a two-week and an annual examination. Comparison subjects were given only an appointment for an annual examination. Norplant users not returning within 5 weeks or any subject not presenting within 12 months for an annual examination, were considered non-compliant. RESULTS: Eighty-eight adolescents received Norplant during the study period and the records of 85 were available for review. Only 48 of the 85 Norplant users returned for scheduled two-week check-up, while 18 of 43 subjects who had Norplant at least 12 months were compliant with annual examinations. The compliance rate with annual examinations among the 89 subjects not using Norplant was 38%, not dissimilar from that of the Norplant group. CONCLUSIONS: These data demonstrate that compliance with return appointments for reproductive health care among adolescent Norplant users is poor but not significantly worse than that of non-users of Norplant. Strategies promoting the benefits of return visits need to be improved for adolescents receiving contraception.

PIP: Although the long-term protection from pregnancy conferred by Norplant use makes this a potentially effective method for adolescents, there are concerns that teenagers with implants will not be motivated to return for routine reproductive health examinations. To assess this possibility, compliance with scheduled return clinic appointments among 85 Norplant acceptors aged 18 years and younger and 89 age- and race-matched controls was compared through retrospective review of records at a community-based family planning clinic in North Carolina. Only 14 Norplant acceptors returned to have the insertion site examined within five weeks of insertion; another seven appeared for the initial examination after a reminder was mailed, yielding a 25% compliance rate. In terms of the annual examination, 18 of the 43 subjects who had used Norplant for at least 12 months and 34 of the 89 controls were compliant. There was no significant difference in this compliance rate between cases (41.9%) and users of other methods (38.2%). Among cases, the records showed that appointment compliance after Norplant insertion was not significantly lower than it had been among these women when they were using other methods. Only three Norplant acceptors discontinued the method, indicating a high degree of user satisfaction. Although these findings indicate that Norplant use does not increase the risk of poor compliance with reproductive health care, they indicate a need to convince teenagers of the benefits of such care, especially for the detection of sexually transmitted diseases.

Magnitude of stress experienced by baseball and softball umpires.

This study surveyed 782 certified baseball and softball umpires from randomly chosen umpire associations in one state to assess how much stress they experienced while officiating. The mean stress score was between "very little" and "a moderate amount," although 4.5% of the respondents reported "quite a bit" or "a great deal" of stress. The mean stress score may have been attenuated by the umpires' reluctance to admit stressful experiences or by collection of data after the season was over.