Ataxia and mobility in children following surgical resection of posterior fossa tumour: A longitudinal cohort study.

PURPOSE: To report the course of ataxia in children up to 2 years post-operatively, following surgical resection of a posterior fossa tumour (PFT). METHODS: Thirty-five children, (median age 9 years, range 4-15) having resection of PFT, were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), Brief Ataxia Rating Scale (BARS) and the mobility domain of the Paediatric Evaluation of Disability Index (PEDI-m) at initial post-operative period (baseline), 3 months, 1 year and 2 years post-operatively. RESULTS: Baseline median scores of the SARA and BARS were 8.5 (range 0-35.5), and 7 (0-25) respectively. Ataxia improved at 3 months (median SARA and BARS reduction 3.5 and 4, respectively). Additional gradual improvements in SARA were recorded at 1 (median reduction 2) and 2 years post-operatively (median reduction 0.5). Median baseline PEDI-m was 54.75 (range 15.2-100) with improvement at 3 months (median increase 36.95) and small improvement at 1 year (median increase 2.5) and 2 years (median increase 5.8). Children with medulloblastoma and midline tumours (median baseline SARA 10 and 11, respectively) demonstrated more severe ataxia than children with low-grade gliomas and unilateral tumours (median baseline SARA 7.5 and 6.5, respectively). CONCLUSION: The largest improvement in ataxia scores and functional mobility scores is demonstrated within the first 3 months post-operatively, but ongoing gradual improvement is observed at 2 years. Children with medulloblastoma and midline tumour demonstrated higher ataxia scores long term.

Audio/visual recording of doctors in hospitals: Guideline from the Association of Anaesthetists.

Guidelines are presented that summarise the legal position regarding the audio/visual recording of doctors and others in hospitals. In general, there are few, if any, legal grounds for refusing a request by patients to record procedures and/or discussions with clinicians, although some staff may feel uncomfortable being recorded. Trusts and others are advised to draw up local policies and ensure staff and patients are adequately informed.

Inter-rater reliability and validity of two ataxia rating scales in children with brain tumours.

OBJECTIVES: This study aimed to investigate the inter-rater reliability and construct validity of the Scale for the Assessment and Rating of Ataxia (SARA) and Brief Ataxia Rating Scale (BARS) in children with posterior fossa tumours. These scales have been developed for adults with genetic ataxias, and the performance of these scales in children with brain tumours has not previously been described. METHODS: The participants, who had undergone surgical resection for a posterior fossa tumour (inclusion criteria age 4-18 years), were recruited from the neuro-oncology service at a tertiary children's hospital. Children were assessed using the SARA, BARS and Paediatric Evaluation of Disability Index (PEDI) mobility domain, a measure of function. Children were independently rated by two therapists to determine the inter-rater reliability of the SARA and BARS. The construct validity was determined by assessing the correlation between the two scales with the PEDI. RESULTS: Forty-four children were recruited. Inter-rater reliability was good for both scales, demonstrating the strong correlations (SARA, r = 0.94; BARS, r = 0.91) and the good consistency (93 % of SARA and 90 % of BARS paired scores differing by less than 2 points) between two raters. Both ataxia scales demonstrated a strong negative correlation with the mobility domain of the PEDI (SARA, r = -0.77; BARS, r = -0.76), indicating that more severe ataxia was associated with worse mobility. The mean time for completion of the SARA was 4.5 and 2.7 min for the BARS. CONCLUSIONS: The SARA and BARS are reliable and valid measures and appear to be of equal value in determining the severity of ataxia in children with posterior fossa tumours.

The influence of managed care on supply of certified nurse-midwives: an evaluation of the physician dominance thesis.

A key debate over the nature of professional power centers on the maintenance of physician dominance within the system of professions in health care. The changes in health care delivery and financing brought by managed care present a new context for evaluating the physician dominance thesis. I propose that increases in the supply of certified nurse-midwives, a "contending" health care professional group, are related to the expansion of managed care and may signal a decline in physician dominance. I analyze state-level data compiled from governmental, health professional, and industry sources to determine the influence of managed care market penetration, physician supply, state policy context, and demographic factors on the state-level supply of nurse-midwives. Results indicate that, despite high physician supply, nurse-midwife supply is higher in states with higher managed care penetration, as well as in those with more favorable state policy environments and a more educated demographic base. Outcomes from a series of hypothesis tests support my assertion that the expansion of managed care is altering the jurisdictional boundaries in the system of professions in health care, eroding the dominance of physicians while creating new openings for nurse-midwives.

Effect of lateral versus supine wedged position on development of spinal blockade and hypotension.

Aortocaval compression may not be completely prevented by the supine wedged or tilted positions. It is commonly believed, however, that the unmodified full lateral position after induction of spinal anaesthesia might allow excessive spread of the block. We therefore compared baseline arterial pressures in the supine wedged, sitting, tilted and full lateral positions in 40 women who were about to undergo elective caesarean section. They were then given spinal anaesthesia in the left lateral position and randomised to be turned to the right lateral or the supine wedged position, after which speed of onset and spread of blockade to cold sensation were measured every 2 min for 10 min and mean arterial pressure and ephedrine requirement were recorded every minute for 20 min. Baseline mean arterial pressure was 9 mmHg (95% CI 3 to 14) lower in the left lateral (measured in the upper arm) than in the sitting position; those in the supine wedged and tilted positions were intermediate. Following spinal anaesthesia, hypotension (defined as a reading

Time management and leadership styles: an empirical study of long-term health care administrators.

Is there a relationship between the type of leadership style employed by long-term health care administrators and the effective use and management of time? This paper describes a 1989 study of 188 administrators of skilled nursing facilities and intermediate care facilities in Connecticut. Two self-rating instruments were employed: the Executive Time Management Inventory (Hartley, Kramer, et al.) and the LEAD-Self instrument (Hersey and Blanchard). Four hypotheses were tested at the .05 level of significance to examine relationships among time management, leadership style, size of facility, administrator experience, and cost factors. Statistical procedures included Pearson Product-Moment correlations, analysis of variance, t-tests, and partial correlations. Results of the study included (1) time management effectiveness increased as administrators gained more experience; (2) no significant relationship existed between type of leadership style and time management effectiveness; (3) women administrators perceived themselves as significantly more effective time managers than men did; (4) most health care administrators employed the same primary leadership style: "selling," which is defined as high relationship/high task; and (5) institutional size was not related to the time management effectiveness of the administrator. The findings have implications for pre-service and in-service training and for future studies in health administration education.

Estimation of "safe doses" in carcinogenic experiments.

The statistical methodology for carcinogenic safety testing here developed has the following advantages: (1) Rather than making possibly unwarranted assumptions about a minimum slope in a dose response relationship, the present method represents an objective data based method of estimating "safe" doses. It is applicable to any specified permissible risk (of exceeding the spontaneous rate) and the latter must of course be specified by F.D.A. (2) Although the model which is used for the estimation of safe doses and their lower confidence points is parametric it comprises an adequately large number of parameters to allow for differences in the idiosyncracies of suspected carcinogens, host species and to a limited degree for variations in the experimental protocols. (3) The same computer program will cover the analysis of an experiments in which times to tumor have been recorded as well as experiments in which only tumor incidence rates have been recorded or mixtures of the two. "Better experimentation" is "rewarded" in that the lower confidence limits for the "safe doses" should be higher and more closely approach the true safe dose as the experimental effort increases. (4) The maximum likelihood estimation procedure is sophisticated and has asymptotic optimality properties. It utilizes the latest techniques of "convex programming" and the computer algorithm is straightforward and fast. The methodology proposed here also has the following shortcomings: (1) The model is (multi)parametric. However, it is of the form of the product model for age specific hazard rates which is now widely accepted. (2) Robustness studies on the effect of model breakdown on the estimated safe doses are as yet limited and should be followed up with more extensive studies. (3) Obviously no estimates of "safe doses" can be made if the spontaneous incidence rate is zero and the experimental dose levels have been chosen too small and no tumors have been observed. Similarly if the experimental doses are too small and the tumor incidence rates are all comparable with the spontaneous rate the estimation procedure is afflicted by extremely large errors. The situation improves slightly if the incidence for the highest dose level is higher than that of the lower dose levels which are all approximately equal. In such situations more satisfactory experimental data are needed. Some general recommendations are as follows: (1) Whenever possible it is preferable to record times to tumor and not just incidence rates. However, for experiments of sufficiently long duration necropsies following the varying times of death will provide adequate information on the time dependence of tumor incidence. It may also be advisable to deliberately vary the times of sacrifice to two or three different times. (2) Other considerations being equal it is preferable to have a large number of dose levels rather than more animals per dose level...

A "super-population viewpoint' for finite population sampling.

Frequently it is reasonable for a sample surveyor to view the finite population of interest as an independent sample of size N from an infinite super-population. This super-population viewpoint is contrasted to the classical frequentist theory of finite population sampling and the classical theory of infinite population sampling. A new technique for making inferences about finite population "parameters' is developed and shown to be applicable for any survey design. Two example applications are given: the estimation of strata- and population means in stratified sampling and the use of the so-called regression estimators for the same purpose.

Respiration audiometry with pre-school children.

Respiration audiometry with a strain gauge writeout on a dynograph was attempted with 12 children aged 3 yrs 6 mo to 4 yrs 11 mo. Test signals were at 1 kc/s of 1 sec duration presented at the beginning of a respiratory cycle, from --10 to 40 db HL in 2 ascending series (test and retest). Both series could be completed on only 5 Ss, due to interruptive behavior patterns. Of all 105 presentations, 13 were judged positive; of these, 9 were at levels lower than the play audiometry HTL (false-positive). For no S could a respiration audiometry HTL be reasonably estimated. Due to the low ratio of respiratory responses at or above behavioral HTL, the low rate of test completion for the majority of preschool Ss, and the presence of significant numbers of false-positive responses, it was recommended that further research be carried out before respiration audiometry is seriously considered or he paedoaudiologic clinic.

The impact of a drug information sheet on the understanding and attitude of patients about drugs.

A proposed Food and Drug Administration program to require written information with prescription drugs could cost $500 million annually; the American Medical Association has implemented a similar, voluntary program costing more than $3 million. However, the educational impact of written drug information has not been studied. We evaluated one-page drug information sheets using an objective examination. The baseline score of 71 patients was 3.9 of 6.0. Patients tested before and one day after receiving the drug sheet improved their score by +1.4. In the second phase, patients randomized to receive the drug sheet improved their score after one month by +1.1; those not given the sheet had no improvement. Changes in attitudes and incidence of reported adverse effects seemed to be random and unrelated to the information sheet. Thus, a drug information sheet may be a useful adjunct to patient education.

KIE: The educational value of drug information sheets was studied by the authors, who employed specially designed one-page medication sheets on digoxin and propranolol hydrochloride, on hospital patients and outpatients taking one or both drugs. Some patients were tested on their knowledge about their medications before and after reading the information sheets, some were tested only after reading the sheets, and some were tested and retested without access to the sheets. The scores of the patients who had read the sheets were higher than those of the patients who had not. The authors conclude that the sheets can yield a small but significant improvement in patients' understanding of the drugs they take, and that a drug information sheet "may be a useful adjunct" to a physician-initiated discussion about medication.

The 6-min walk and peak oxygen consumption in advanced heart failure: aerobic capacity and survival.

BACKGROUND: This study sought to determine to what extent the 6-min walk (6MW) distance in advanced heart failure predicts aerobic capacity and provides comparable information regarding survival. Peak oxygen uptake ( VO(2)) and the 6MW both describe function and predict outcome over a wide range of heart failure, but their determinants and implications may differ within a narrower clinical spectrum. This study compared 6MW with aerobic capacity both at peak exercise and during low-level cycling. METHODS AND RESULTS: Both the 6MW and symptom-limited cycle ergometry were performed by 307 patients of whom 264 patients additionally performed 6 min of 20-W cycling to estimate aerobic capacity during sustained low-level activity. In the first 198 patients, multivariate analysis of survival was performed with the 6MW and peak VO (2). Patients achieved the 6MW of 393 +/- 104 m and peak VO (2) of 14 +/- 5 mL/kg per minute. Although low peak VO (2) was more likely with the shorter 6MW, the relation was weak within peak VO (2) range of 10 to 20 mL/kg per minute (n = 213, 69% of patients, r = 0.28). During 20-W exercise, VO (2) was 9.2 +/- 2.0 mL/kg per minute, with respiratory exchange ratio poorly correlated with the 6MW. In contrast to peak VO (2), the 6MW in meters did not predict survival. Division into short, medium, and long walks, however, supplemented simple clinical description. CONCLUSIONS: Although helpful in broader populations for identification of patients with obvious clinical compromise, the 6MW distance is not a surrogate for peak VO (2) in assessing aerobic capacity or prognosis for individuals with advanced heart failure.