'Our culture makes us strong': Understanding and working with community strengths among Aboriginal people in western Sydney.

BACKGROUND: Strengths-based approaches to health care are often seen as an alternative to deficit-based approaches and are common in Aboriginal health settings. Despite this, there is little existing research that describes Aboriginal peoples' perspectives about the strengths of their communities. This paper describes cultural strengths and resources as understood by Aboriginal people living in western Sydney. METHODS: In-depth interviews were used to collect qualitative data from two communities on Dharug and Dharrawal Country in western Sydney Australia. Data come from a larger study, which focused on how cultural strengths supported sexual well-being. Fifty-two interviews were conducted with Aboriginal young people (aged 16-24 years) by trained peer interviewers. Additionally, 16 interviews with Aboriginal adults (25 years and older) were conducted by members of the research team. FINDINGS AND DISCUSSION: While opinions varied, four key areas of cultural strength were identified: (1) strong kinship relationships; (2) knowledge sharing; (3) shared experiences, identities, and values; and (4) knowing Country. Throughout these four themes, the sense of connection and belonging is viewed as an important overarching theme. CONCLUSION: Communities are not homogenous with regard to what they view as cultural strengths. Knowing Country and practising culture meant different things to different individuals while providing a similar sense of belonging, connection, and identity. SO WHAT: Health service providers, policies, and programs can use this information to understand the continuing impacts of past policies and events whilst recognising that each community has strengths that can be drawn upon to improve service engagement, knowledge sharing, and health outcomes.

[The effects of covid-19 on psychiatry training in the Netherlands]. / De invloed van COVID-19 op de opleiding psychiatrie in Nederland.

Background The COVID-19 pandemic changes the training of residents and could offer new opportunities. Aim Gaining insight in the effects of the impact of the COVID-19-pandemic on psychiatry residents. Method A digital questionnaire was designed to evaluate the impact of the COVID-19 pandemic on educational activities. The experience of residents with regards to safety in the workplace, social cohesion with their peers and the involvement of supervisors were examined. Results We approached 34 training institutions. 24 chief residents of the resident group completed the questionnaire. The quality of regional education was considered unchanged by 20% and local education by 33%. Digital communication increased the participation of psychiatrists in the general report and education activities and ensured less travel time. Nevertheless, respondents missed contact with their peers, safety of residents was compromised at five institutions and half of all respondents indicated a lack of personal protective equipment. Conclusions A majority of the psychiatry residents are satisfied with their training during this historic pandemic, but the quality of local and regional education was considered changed, and not being beneficial. The challenge remains for stimulating contact with peers, monitoring the quality of education in general as in psychotherapy and providing personal protective equipment. Tijdschrift voor Psychiatrie 63(2021)1, 16-21.

Persistent C-peptide is associated with reduced hypoglycaemia but not HbA1c in adults with longstanding Type 1 diabetes: evidence for lack of intensive treatment in UK clinical practice?

AIMS: Most people with Type 1 diabetes have low levels of persistent endogenous insulin production. The Diabetes Control and Complications Trial showed that close to diagnosis preserved endogenous insulin was associated with lower HbA1c , hypoglycaemia and complication rates, when intensively treated. We aimed to assess the clinical impact of persistent C-peptide on rate of hypoglycaemia and HbA1c in those with long duration (> 5 years) Type 1 diabetes. METHODS: We conducted a cross-sectional case-control study of 221 people (median age 24 years) with Type 1 diabetes. We confirmed ongoing endogenous insulin secretion by measuring C-peptide after a mixed-meal tolerance test. We compared self-reported hypoglycaemia (n = 160), HbA1c , insulin dose and microvascular complications (n = 140) in those with preserved and low C-peptide. RESULTS: Stimulated median (IQR) C-peptide was 114 (43, 273) pmol/l and < 3 (< 3, < 3) pmol/l in those with preserved and low C-peptide respectively. Participants with preserved C-peptide had lower reported monthly rates of hypoglycaemia, with 21% fewer symptomatic episodes, 5.9 vs. 7.5 [incidence rate ratio (IRR) 0.79, P = 0.001], and 65% fewer asymptomatic episodes, 1.0 vs. 2.9 (IRR 0.35, P < 0.001). Those with preserved C-peptide had a lower insulin dose (0.68 vs. 0.81 units/kg, P = 0.01) but similar HbA1c (preserved 69 vs. low 67 mmol/mol, P = 0.06). CONCLUSIONS: Adults with Type 1 diabetes and preserved endogenous insulin production receiving usual care in the UK have lower daily insulin doses and fewer self-reported hypoglycaemic episodes, but no difference in HbA1c . This is consistent with non-intensive treatment in previous studies, and suggests a need to consider therapy intensification to gain full benefit of preserved endogenous insulin.

Evidence of frequent dosing errors in paediatrics and intervention to reduce such prescribing errors.

WHAT IS KNOWN AND OBJECTIVE: Drug prescribing is an essential part of inpatient care, and prescription errors/omissions have the potential to lead to disastrous consequences. Paediatric inpatient prescribing is particularly sensitive to error due to the weight-adjusted dosing of many medications prescribed in the acute setting. Previous studies have described a high incidence of error in adult drug chart completion, although no studies to date have assessed the error seen in the paediatric setting or accuracy of weight-adjusted dosing. Our objective was to determine the degree of error seen in paediatric drug prescribing for patients admitted under the care of oral and maxillofacial surgery and to explore practical and accessible methods through which error can be reduced. METHODS: We retrospectively evaluated inpatient drug charts to assess the prescribing practices seen for patients admitted under the care of oral and maxillofacial surgery in an NHS children's hospital and compared these findings against established hospital standards. The study also examined the distribution and variability of weight-adjusted dose prescribing in an attempt to set targets for auditing improvements following the implementation of changes. RESULTS AND DISCUSSION: Prescriptions were completed by a combination of doctors from maxillofacial and anaesthetic teams, with similar error rates seen in both specialties. 13% of drug charts contained one or more errors in frequency prescribing. For weight-adjusted drugs, a median under-dosage of -5·4% was noted, with an IQR of -12 to -0·6. Our study has confirmed that errors are common both in the manual completion of paediatric prescription charts and in the calculation of weight-adjusted doses. WHAT IS NEW AND CONCLUSION: We conclude that inaccuracies in prescription chart completion are a frequent occurrence and that dosage and frequency-prescribing errors may potentially act synergistically to create a significant disparity between the recommended and actual amount of drug that is delivered. Our study demonstrates a clear bias towards under-prescribing weight-adjusted doses which may be contributing to reduced efficacy of analgesia, among other drugs. Simple methods can be implemented on a specialty basis to improve the accuracy of both drug chart completion and weight-adjusted dosing.

Patients' narratives of orthognathic treatment for facial asymmetry: a qualitative study.

To explore patients' experiences of orthognathic treatment for facial asymmetry and their adaptation to facial changes after surgery, we did a qualitative, cross-sectional study of patients after treatment for non-cleft asymmetry at two UK sites. A total of 15 patients aged 19-40 years were approached after being identified using patient databases and clinical notes. Individual and photo-elicitation interviews were conducted covering experiences prior to treatment, during treatment, and after surgery. Interviews were transcribed and thematic narrative analysis undertaken. Participants were largely positive about their orthognathic treatment. The following themes were identified: preoperative (becoming aware, negative impacts of asymmetry, committing to treatment, establishing expectations), pre-surgery orthodontics and inpatient experiences (challenges and coping strategies, preparedness, support, and shared experiences); and postoperative (surgery as 'worth it', positive impacts of treatment, adapting to facial change). Undergoing orthognathic surgery was portrayed as a journey involving recognisable narratives (treatment unfinished, threat of liminality, treatment as resolution, and treatment as transformation). Patients' experiences of facial asymmetry are associated with feeling 'abnormal', and negative impacts, and orthognathic treatment for facial asymmetry is worthwhile. Having the feeling that something is 'wrong' legitimised by clinicians allows patients access to a recognisable treatment narrative (resolution). Orthognathic treatment is also described as transformation from 'normal abnormality' to being 'normal'. Nevertheless, the associated challenges can be frustrating, particularly if resolution is hard to envisage. Further psychological input could help patients cope with these challenges and the complex process of adapting to facial change.

Enzymatic sulfation of bile salts. Partial purification and characterization of an enzyme from rat liver that catalyzes the sulfation of bile salts.

An enzyme system which catalyzes the transfer of sulfate group from 3'-phosphoadenosine-5'-phosphosulfate to bile salts has been identified and characterized from rat liver. The enzyme is present in the cytosol fraction of liver cells. The apparent Km value for 3'-phosphoadenosine-5'-phosphosulfate was 8 - 10(-6) M andhat for taurolithocholate was 5 - 10(-5) M. Sulfation occurred with conjugated as well as unconjugated bile salts, however, the rate of sulfation was higher with conjugated than unconjugated. The enzyme was present in rat liver and kidney, but not detectable in brain, lung, heart, spleen or intestinal mucosa. The activity is completely inhibited by p-chloromercuribenzoate indicating the enzyme requires a sulfhydryl group for activity. A molecular weight of 130 000 was estimated by gel-filtration technique and the enzyme shows an isoelectric point of 5.3.

[Diagnostic image (227). A 7-year-old boy with oedema]. / Diagnose in beeld (227). Een 7-jarige jongen met oedeem.

Protein-losing gastroenteropathy with oedema, Ménétrier's disease, was diagnosed in a 7-year-old boy.

Fetal growth and the function of the adrenal cortex in preterm infants.

Small for gestational age preterm infants have a higher risk of neonatal morbidity compared to appropriate for gestational age preterm infants. A diminished adrenal response to stress may be involved in the higher postnatal morbidity. The adrenal cortex response in relation to fetal growth was studied by ACTH stimulation tests in 43 preterm infants (born < or = 32 wk). The cortisol and 17-hydroxyprogesterone (17-OHP) responses to 1 microg/kg ACTH were analyzed in relation to birth weight SD scores (BW-SDS) corrected for gestational age, gender, and parity. BW-SDS was significantly associated with the cortisol and 17-OHP response. Infants with the lowest BW-SDS had the lowest cortisol levels after stimulation. No effect of size at birth was found on the ratio between cortisol and 17-OHP. In addition, basal cortisone levels in a single blood sample were higher in infants with the lowest BW-SDS than in infants with higher BW-SDS, but the ratio between cortisol and cortisone was comparable in the two groups. We conclude that the response of cortisol and 17-OHP to ACTH stimulation in preterm infants is related to fetal growth. The lack of influence of fetal growth on the ratio between cortisol and 17-OHP after ACTH stimulation suggests that the activities of 21- and 11 beta-hydroxylase are not affected. The lower adrenal response to stimulation may be important in neonatal morbidity and possibly the development of disease in later life in growth-restricted preterm infants.

Design of a multicenter trial to evaluate long-term life-style intervention in adults with high-normal blood pressure levels. Trials of Hypertension Prevention (phase II). Trials of Hypertension Prevention (TOHP) Collaborative Research Group.

Phase II of the Trials of Hypertension Prevention (TOHP) is a multicenter, randomized trial sponsored by the National Heart, Lung, and Blood Institute designed to test whether weight loss alone, sodium reduction alone, or the combination of weight loss and sodium reduction will decrease diastolic (DBP) and systolic blood pressure (SBP) as well as the incidence of hypertension (DBP > or = 90 mm Hg, SBP > or = 140 mm Hg, and/or use of antihypertensive medications) in subjects with high-normal DBP (83 to 89 mm Hg) and SBP less than 140 mm Hg at entry. These interventions were chosen for longer-term testing with end points including hypertension prevention as well as blood pressure (BP) change based on their demonstrated short-term efficacy in reducing BP in phase I of TOHP. The phase II study population is comprised of 2382 participants (1566 men and 816 women) who are 110 to 165% of desirable body weight, allocated at random to the four treatment arms using a 2 x 2 factorial design. The trial has 80% power to detect an overall treatment effect on DBP of 1.2 mm Hg for weight loss or sodium reduction and a difference of 1.6 mm Hg between the combined intervention and placebo groups. BP observers are blinded to participant treatment assignments. Participants will be followed for 3 to 4 years. This trial may have important public policy implications concerning the ability of life-style modifications to reduce BP and prevent the development of hypertension over the long term, thereby avoiding the need for drug therapy which while effective is costly and may have side effects.

Glucocorticoids and lung development in the fetus and preterm infant.

During the final prenatal period of fetal lung development in humans, important maturational processes occur, including the production of surfactant necessary to decrease surface tension at the air-liquid interface of the alveoli. During early gestation, the glucocorticoid receptor is expressed in the fetal lung, and glucocorticoids stimulate the production of surfactant-associated proteins and increase phospholipid synthesis by enhancing the activity of phosphatidylcholine. Other glucocorticoid-induced effects may include stimulation of cell maturation and differentiation, inhibition of DNA synthesis, changes in interstitial tissue components, stimulation of antioxidant enzymes, and regulation of pulmonary fluid metabolism. Recently, it was suggested that glucocorticoids are also important in postnatal pulmonary development, and may be related to the development of neonatal lung disease in preterm infants. Surfactant deficiency that can be prevented by antenatal corticosteroid treatment causes infant respiratory distress syndrome and requires mechanical ventilation. Ventilation by itself or in combination with high levels of oxygen, fluid overload, pulmonary infections, sepsis, and air leak syndrome causes an acute pulmonary inflammatory reaction that may result in chronic lung disease or bronchopulmonary dysplasia. Glucocorticoids are effective in the treatment of chronic lung disease of prematurity and regulate the inflammatory response by the interaction with transcription factors such as nuclear factor kappaB and activated protein 1. Indeed, inflammatory cells and the levels of chemokines and cytokines in bronchoalveolar fluid decrease after dexamethasone treatment. However, treatment of fetuses and preterm infants with repeated and/or high doses of corticosteroids may have considerable long-term side effects on somatic, brain, and lung growth. The difficult balance between short-term gain and the possible long-term side effects of glucocorticoids in preterms remains a difficult issue.

Influence of window size in small-window colour measurement, particularly of teeth.

Tooth colour is often measured with a small window for illumination and measurement. This causes edge loss of the light, resulting in systematic errors in colour coordinates. This paper gives a quantification of the edge losses, and explains their cause. We measured reflectance spectra for 27 Formalin fixated extracted incisors using a small-window reflectance spectrophotometer equipped with external diaphragms of 3, 4, and 5 mm diameter, and using a spectroradiometer. We calculated the colour coordinates L*a*b* from these spectra. Finally, 16 randomly chosen teeth were illuminated with a pencil beam (lambda = 543 nm, and lambda = 633 nm) while the emerging light was measured as a function of distance from the illuminated spot using a CCD detector. These data were used to calculate small-window edge losses, and thus to predict the small-window reflectance factors relative to spectroradiometrically determined reflectance, at both 543 nm and 633 nm. In all instruments the same spot on the tooth was illuminated and measured, and the teeth were always wet. Colour coordinates for the small-window colour measurements deviate significantly from those determined using the spectroradiometer. These deviations can be explained from the wavelength-dependant edge loss that arises in small-window colour measurement.

Development of the hypothalamic-pituitary-adrenal axis in the fetus and preterm infant.

The development of the hypothalamic-pituitary-adrenal (HPA) axis in the human fetus is a complex process. The feto-placental unit may be responsible for important maturational processes in vital organ systems in the fetus. A late gestational cortisol surge may be important in fetal maturation, particularly maturation of the lungs. Several striking differences exist between the function of the HPA axis in the fetus and in adults, such as a relative deficiency of 3beta-hydroxysteroid dehydrogenase in the fetal adrenal cortex. With the transition from intrauterine to extra-uterine life several changes occur in the function of the HPA axis. In infants born before term, the function of the HPA axis may still be immature at both the central and adrenal level. This immaturity of the HPA axis may be important in the development of neonatal morbidity. The present review describes the development of the HPA axis in the fetus and in preterm infants and discusses the possible role of HPA immaturity in the development of neonatal morbidity.

Evaluation of screening tests for colorectal cancer.

The following guidelines are proposed for the asymptomatic patient representing for routine examination. Instruct the patient to eat All Bran cereal or a similar product for breakfast for three consecutive days prior to the day of appointment. At the time of appointment the stool obtained from rectal examination or from a spontaneous bowel movement is checked for occult blood using the guaiac method. If the findings are negative, no further tests are recommended. If positive, the patient is given complete dietary instructions in a non-meat, high-residue diet with avoidance of beets, horseradish, vitamins, or aspirin-containing compounds. The patient is then given six Hemoccult or Quikcult slides and is instructed to prepare two fecal slides from each stool specimen daily for three days. If these are all negative when tested, no further studies are necessary. If one or more are positive, however, sigmoidoscopic examination and colon and upper gastrointestinal radiography should be carried out in that order. Evidence that early lesions (Duke A or B) are detected and the cure rate improved with this procedure is quite convincing.

Endoscopic sinus surgery for nasal polyps in children: results.

Functional endoscopic sinus surgery (FESS) was performed on 21 children with nasal polyps, who had a total of 34 operations, on 65 sides. Retrospectively, we reviewed the pre-operative symptoms, pre-operative findings and results of FESS. The diagnoses were made with anterior rhinoscopy and CT scan. Allergy could be confirmed in 24%. Half of the children (52%) had been previously operated on because of nasal polyps. They had more recurrences and worse results than children who underwent primary FESS. The subjective results were good in 77% with a mean follow-up of more than two years. However, a poor correlation between subjective and objective results was noted. Minor complications were seen in 9.2% of 65 sides operated on. The specific advantages of FESS in children are discussed.

[Non-respiratory cyanosis in the newborn]. / Niet-respiratoire cyanose bij de pasgeborene.

Four term babies, three boys and one girl, became cyanotic shortly after birth. In two cases the cause was maternal use of drugs: methemoglobinaemia due to use of a chromate and depression of the nervous system due to clomipramine. They recovered. A third child suffered cerebral infarction and was left with decreased left-arm function. The fourth child had a hypoplastic left heart and died. Central cyanosis in a newborn should be cause for concern. A thorough case history should be taken and extensive physical examination carried out. In case of doubt additional diagnostic tests should be performed.

[Treatment of acute ethmoiditis according to a protocol based on clinical stage]. / Behandeling van acute etmoïditis volgens een protocol gebaseerd op het klinische stadium.

OBJECTIVE: To describe the results of application of a systematic treatment protocol, meant to reduce the risk of serious complications, when treating acute ethmoiditis. DESIGN: Prospective study. SETTING: Academic hospital of the 'Vrije Universiteit (VU)', Amsterdam, The Netherlands. METHOD: From January 1988 to March 1994, 25 children with acute ethmoiditis were admitted to the VU hospital. Eight of them had Chandler stage I, 8 stage II, 3 stage III, 3 stage IV and 3 stage V. The treatment protocol was stepwise, based on the Chandler stages and focused on intensive antibiotic treatment in combination with surgical drainage of the ethmoid complex and (or) the orbit. RESULTS: All children with ethmoiditis stages I-III were cured without rest symptoms. One patient with ethmoiditis stage IV and a pre-existent lymphatic leukaemia died of pulmonary complications of a massive fungal infection, 8 months after treatment. One patient with ethmoiditis stage V finally had permanent psychomotor retardation. CONCLUSION: The used treatment protocol offered the possibility to treat patients with acute ethmoiditis stepwise, depending on stage, with satisfying results. Especially the treatment result in patients with ethmoiditis stage V was good.

A reappraisal of percutaneous liver biopsy in clinical practice.

The diagnostic yield of 101 consecutive percutaneous liver biopsies was assessed. Adequate tissue was obtained in most specimens. Even in the presence of an adequate specimen, other procedures were often necessary to rule out other diagnostic possibilities not explained nor completely ruled out by percutaneous liver biopsy alone. With the current diagnostic procedures available to the clinician which have low morbidity and low mortality, the use of blind percutaneous liver biopsy as an initial diagnostic step in certain types of liver disease should be reassessed.

[Observing the tooth. The paths of light in visual and instrumental observation]. / Kijken naar de tand. De gang van het licht bij visuele en instrumentele waarneming.

The light we observe when we look at a tooth has travelled a long way through the tooth. A large fraction has passed through the dentine. There is also a sideways displacement: the point of entrance into the tooth is about 2 mm away from the point of exit. This implies that tooth color cannot correctly be measured with an instrument employing a single circular window for both illumination and measurement. Visual caries diagnosis of smooth surfaces and with Fiber Optic Trans Illumination (FOTI) is discussed in terms of light paths through the tooth.