First nations people's perspectives on barriers and supports for enhancing HPV vaccination: Foundations for sustainable, community-driven strategies.

OBJECTIVE: In Canada, Indigenous people have higher human papillomavirus (HPV) infection rates, lower screening rates for cervical cancer, and higher rates of invasive cancer, leading to worse cervical cancer-related outcomes than observed in non-Indigenous Canadian women. Lingering harms from European colonization drive these health inequities and create public health challenges. Policy guidance is needed to optimize HPV vaccination rates and, thereby, decrease the burden of HPV-related illness, including high-morbidity surgical procedures and chemo-radiotherapy. The Enhancing HPV Vaccination In First Nations Populations in Alberta (EHVINA) project focuses on First Nations, a diverse subset of recognized Indigenous people in Canada, and seeks to increase HPV vaccination among girls and boys living in First Nation communities. METHODS: Developing an effective strategy requires partnership with affected communities to better understand knowledge and perceptions about cancer, healthcare, and the HPV vaccine. A 2017 community gathering was convened to engage First Nations community members, health directors, and health services researchers in dialogue around unique barriers and supports to HPV vaccination in Alberta. Voices of community Elders, parents, health directors, and cancer survivors (n=24) are presented as qualitative evidence to help inform intervention design. RESULTS: Key findings from discussions indicate barriers to HPV vaccination include resource constraints and service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, and community sensitivities regarding sexual health promotion. Supports were identified as strengthened inter-generational relationships in communities. CONCLUSIONS AND FUTURE DIRECTION: Ongoing dialogue and co-development of community-based strategies to increase HPV vaccine uptake are required. The identification of possible barriers to HPV vaccination in a Canadian Indigenous population contributes to limited global literature on this subject and may inform researchers and policy makers who work with Indigenous populations in other regions.

Establishment of two forensic medicine OSCE stations on the subject of external post-mortem examination.

An improvement in quality of medical external post-mortem examinations among others can be achieved by more intensive training of medical students. Modern learning and teaching methods such as e-learning modules and SkillsLab stations should be used for this. The introduction of corresponding methods of assessment such as the OSCE procedure is necessary to test the success of learning. In Halle (Germany), two OSCE stations on the subject of external post-mortem examinations were introduced in 2016. The 'practical external post-mortem examination' station test skills and abilities students have learned during practical external post-mortem examination in small group classes on a simulation doll. At the 'death certificate' station, an original death certificate must be filled in, testing the knowledge, skills and abilities learned in the SkillsLab station and during e-learning. A total of 148 students took part in the test. At both stations, at least two thirds of the students (69.5 and 81.7%) were able to show good or very good test results. In addition to the strengths, a detailed evaluation of the test results showed that there were still deficits in terms of the corresponding courses (e.g. inspection of the neck region in the small group classes), which will have to be remedied in the future. When analysing the test concept and the test implementation, objectivity was nearly perfect. There was a satisfactory internal consistency and stability over 8 months. Ultimately, in addition to several strengths (such as good understanding and transparency of the checklists) the evaluation of the examiners also showed further potential areas for improvement (e.g. harmonisation of the degree of difficulty for the individual rotations) when designing the OSCE stations. Overall, it was possible to determine that the OSCE testing format is a suitable tool to test external post-mortem examination skills and that conclusions about improvements in teaching can also be drawn from this.

Successful methodology for large-scale surveillance of severe events following influenza vaccination in Canada, 2011 and 2012.

In 2011 and 2012, a nationwide Canadian vaccine safety surveillance network rapidly collected safety data from healthcare workers (HCW) during the first weeks of the annual influenza vaccination campaign. This network provided the first available post-marketing safety data on seasonal influenza vaccines with information on background rates as a comparator. In 2012, these data were used to investigate a possible safety concern regarding a particular vaccine. An online questionnaire was provided to participating HCW two weeks before the annual influenza vaccination campaign for controls, and eight days after influenza vaccination for vaccinees. Control and vaccinees were requested to report health events occurring in the seven days prior to receiving the questionnaire. Control data were used to calculate background rates. HCW reporting a severe event were followed-up by telephone within 48 hours of the online report to validate the report and check on their health status. More than 22,000 vaccinated HCW were enrolled and surveyed over two seasons and > 90% reported no severe event following vaccination. Validated severe event rates were similar in vaccinated HCW and unvaccinated HCW (2.2% vs 2.3%; p < 0.70). The questionnaire was accurately completed for most reported symptoms, matched the validated report and was able to detect events of interest. Prior to the safety concern, the implicated vaccine was in use at one centre. Reassuring safety data were provided to public health authorities 48 hours after the vaccine was temporarily suspended. Data from this and similar networks can be used for rapid evaluation of vaccine safety and for safety assessment as required by the European Medicines Agency in 2015.

Increased risk of invasive pneumococcal disease in haematological and solid-organ malignancies.

Large-scale population-based studies have reported a significant increase in invasive pneumococcal disease (IPD) in those with underlying haematological or solid-organ malignancy, but limited condition-specific data are available on rates of IPD in the adult population. A retrospective chart review of all patients with IPD (identified prospectively) in the province of Alberta, Canada (population ~3·3 million) was conducted from 2000 to 2004 to study the epidemiology of IPD. Rates of IPD in patients with various haematological and solid-organ malignancies were determined by obtaining the number of these patients at risk from the provincial cancer registry. Compared to the attack rate of IPD in the adult population aged ≥18 years (11·0 cases/100,000 per year, 95% CI 10·44-11·65), there were significantly increased rates of IPD in those with lung cancer (143·6 cases/100,000 per year, OR 13·4, 95% CI 9·3-19·4, P<0·001) and multiple myeloma (673·9 cases/100,000 per year, OR 62·8, 95% CI 39·6-99·8, P<0·001). More modestly increased rates of IPD were found in those with chronic lymphocytic leukaemia, acute myeloid leukaemia, acute lymphoblastic leukaemia, and Hodgkin's and non-Hodgkin's lymphoma. There was an increased prevalence of serotype 6A in those with these underlying malignancies, but no other serotypes predominated. Fifty-three percent (48/83) of cases were caused by serotypes in the investigational 13-valent pneumococcal conjugate vaccine (PCV13), and 57/83 (69%) of the cases were caused by serotypes in the 23-valent pneumococcal polysaccharide vaccine (PPV23). The incidence of IPD in adults with certain haematological and solid-organ malignancies is significantly greater than the overall adult population. Such patients should be routinely given pneumococcal polysaccharide vaccine; this population could also be targeted for an expanded valency conjugate vaccine.

The Importance of Consistent Global Forest Aboveground Biomass Product Validation.

Several upcoming satellite missions have core science requirements to produce data for accurate forest aboveground biomass mapping. Largely because of these mission datasets, the number of available biomass products is expected to greatly increase over the coming decade. Despite the recognized importance of biomass mapping for a wide range of science, policy and management applications, there remains no community accepted standard for satellite-based biomass map validation. The Committee on Earth Observing Satellites (CEOS) is developing a protocol to fill this need in advance of the next generation of biomass-relevant satellites, and this paper presents a review of biomass validation practices from a CEOS perspective. We outline the wide range of anticipated user requirements for product accuracy assessment and provide recommendations for the validation of biomass products. These recommendations include the collection of new, high-quality in situ data and the use of airborne lidar biomass maps as tools toward transparent multi-resolution validation. Adoption of community-vetted validation standards and practices will facilitate the uptake of the next generation of biomass products.

Objective structured clinical examination "Death Certificate" station - Computer-based versus conventional exam format.

One option for improving the quality of medical post mortem examinations is through intensified training of medical students, especially in countries where such a requirement exists regardless of the area of specialisation. For this reason, new teaching and learning methods on this topic have recently been introduced. These new approaches include e-learning modules or SkillsLab stations; one way to objectify the resultant learning outcomes is by means of the OSCE process. However, despite offering several advantages, this examination format also requires considerable resources, in particular in regards to medical examiners. For this reason, many clinical disciplines have already implemented computer-based OSCE examination formats. This study investigates whether the conventional exam format for the OSCE forensic "Death Certificate" station could be replaced with a computer-based approach in future. For this study, 123 students completed the OSCE "Death Certificate" station, using both a computer-based and conventional format, half starting with the Computer the other starting with the conventional approach in their OSCE rotation. Assignment of examination cases was random. The examination results for the two stations were compared and both overall results and the individual items of the exam checklist were analysed by means of inferential statistics. Following statistical analysis of examination cases of varying difficulty levels and correction of the repeated measures effect, the results of both examination formats appear to be comparable. Thus, in the descriptive item analysis, while there were some significant differences between the computer-based and conventional OSCE stations, these differences were not reflected in the overall results after a correction factor was applied (e.g. point deductions for assistance from the medical examiner was possible only at the conventional station). Thus, we demonstrate that the computer-based OSCE "Death Certificate" station is a cost-efficient and standardised format for examination that yields results comparable to those from a conventional format exam. Moreover, the examination results also indicate the need to optimize both the test itself (adjusting the degree of difficulty of the case vignettes) and the corresponding instructional and learning methods (including, for example, the use of computer programmes to complete the death certificate in small group formats in the SkillsLab).

The superbugs: evolution, dissemination and fitness.

Since the introduction of antibiotics, bacteria have not only evolved elegant resistance mechanisms to thwart their effect, but have also evolved ways in which to disseminate themselves or their resistance genes to other susceptible bacteria. During the past few years, research has revealed not only how such resistance mechanisms have been able to evolve and to rapidly disseminate, but also how bacteria have, in some cases, been able to adapt to this new burden of resistance with little or no cost to their fitness. Such adaptations make the control of these superbugs all the more difficult.

Bronchial hyperreactivity is correlated with increased baseline airway tone.

Physiologically, airways are not completely relaxed but maintain a baseline airway tone (BAT). Although not fulfilling the criteria for obstructive airway disease, increased BAT may nevertheless be important because the same amount of airway narrowing can be well tolerated or can cause severe airway obstruction depending on the starting point of the narrowing. In this study, we aimed at studying if BAT is correlated with bronchial hyperreactivity (BHR). For in vitro studies, airways in murine lung slices were digitally recorded and the change in cross-sectional area with time was quantified. BAT was measured by the amount of relaxation induced by permeabilization of the cell membrane with beta-escin in zero external calcium. BHR was induced by incubation of lung slices with interleukin-13 (IL-13). T-bet knock-out mice served as an additional model for BHR. T-bet knock-out mice show a shift towards TH2-lymphocytes and display histological as well as functional characteristics of asthma. In vivo, the specific airway resistance of healthy non-smoking volunteers was assessed before and after inhalation of formoterol and bronchial challenge was performed using methacholin. In murine lung slices that had been cultivated without serum, only a minimal BAT could be observed. But, after cultivation with 10 % new born calve serum, airways showed a BAT of approximately 13 % that could be reduced by incubation with an IL-13 receptor antagonist. Atropine, isoproterenol and indomethacin failed to relax airways regardless of cultivation with serum. Incubation of lung slices without serum but with IL-13 increased BAT as well as airway responsiveness to acetylcholine and both effects were more pronounced in small compared to large airways. In lung slices from T-bet knock-out mice, airways were hyperreactive compared to airways in slices from wild type mice and BAT was found to be increased. Again, both effects were more pronounced in small compared to large airways. In human non-smokers without airway obstruction, increased BAT was correlated with bronchial hyperreactivity. We therefore conclude that although not fulfilling the criteria for obstructive airway disease, increased airway tone may yet be relevant in asthma.

Umbilical cord blood graft engineering: challenges and opportunities.

We are entering a very exciting era in umbilical cord blood transplantation (UCBT), where many of the associated formidable challenges may become treatable by ex vivo graft manipulation and/or adoptive immunotherapy utilizing specific cellular products. We envisage the use of double UCBT rather than single UCBT for most patients; this allows for greater ability to treat larger patients as well as to manipulate the graft. Ex vivo expansion and/or fucosylation of one cord will achieve more rapid engraftment, minimize the period of neutropenia and also give certainty that the other cord will provide long-term engraftment/immune reconstitution. The non-expanded (and future dominant) cord could be chosen for characteristics such as better HLA matching to minimize GvHD, or larger cell counts to enable part of the unit to be utilized for the development of specific cellular therapies such as the production of virus-specific T-cells or chimeric-antigen receptor T-cells which are reviewed in this study.

The use of Streptococcus pneumoniae nasopharyngeal isolates from healthy children to predict features of invasive disease.

BACKGROUND: The role of sampling nasopharyngeal carriage isolates of Streptococcus pneumoniae to determine characteristics of isolates causing invasive disease has not been established. METHODS: Data were compared from two 1995 studies of S. pneumoniae in Metropolitan Toronto and Peel Region (population, 3.1 million). The first was a prospective survey of nasopharyngeal (NP) carriage in child care centers. The second was a prospective surveillance for all cases of invasive disease. RESULTS: There were 545 NP S. pneumoniae isolates obtained from 532 children and 96 cases of invasive S. pneumoniae disease in children. The prevalences of reduced antibiotic susceptibility in the NP carriage and invasive studies, respectively, were: penicillin (16% vs. 11%, P=0.29); erythromycin (12% vs. 7%, P=0.25); and multiresistant (16% vs. 12%, P=0.34). The power to rule out a difference between the groups was <30% for each comparison. Trimethoprim/sulfamethoxazole resistance was more common in NP carriage isolates than invasive isolates (38% vs. 23%, P=0.02). Serotype 14 was more common in invasive isolates, whereas serogroup 6 was more common in NP carriage isolates. Antibiotic-resistant isolates were predominantly serogroups 6, 19 and 23 in both studies. CONCLUSIONS: Nasopharyngeal carriage isolates of S. pneumoniae reflect the antibiotic susceptibility rates of invasive isolates found in the same period for most antibiotics. However, even a large study like this may have limited power to detect a difference. The most common NP carriage serotypes are the same as the invasive isolates, although the rank order of specific serotypes is different. Routine surveys of S. pneumoniae NP carriage are not feasible because of the cost of serotyping and limited power of the observations, unless sample sizes are extremely large.

Streptococcus pneumoniae carriage in children attending 59 Canadian child care centers. Toronto Child Care Centre Study Group.

OBJECTIVES: To determine the prevalence of Streptococcus pneumoniae nasopharyngeal carriage, antibiotic resistance patterns, and serotypes; to examine the variability of microbiological findings between child care centers; and to determine risk factors for antibiotic resistance. DESIGN: Point prevalence survey. SETTING: Licensed child care centers in Toronto, Ontario. PARTICIPANTS: Healthy children attending the centers. MAIN OUTCOME MEASURES: Prevalence (simple and adjusted for clustering) of carriage, antibiotic resistance, and serotypes; multivariate analysis of risk factors for resistance. RESULTS: Of 1322 children from 59 centers, 586 (44.3%) carried 599 S. pneumoniae isolates. On the day of study, 129 (10.7%) of 1203 children for whom a questionnaire was completed were taking antibiotics and 336 (227.9%) had taken them in the previous month. Decreased susceptibility to penicillin was found in 102 isolates (17.0%) and 82 (13.7%) were resistant to multiple antibiotics. The most common serotypes, in order, were 6B, 23F, 6A, 19F, 14, 11A, and 19A, composing 78% of all isolates. Microbiological results from individual centers were variable, but the overall prevalence of carriage, antibiotic resistance, and serotypes was not significantly different when adjusted for effects of clustering within centers. Multiple logistic regression determined that age younger than 24 months and antibiotic use within the previous month were significant risk factors for carriage of S. pneumoniae resistant to penicillin, sulfamethoxazole-trimethoprim, and erythromycin. CONCLUSIONS: Efforts to reduce antibiotic use in children should be particularly directed toward young children attending child care centers. Studies of infectious diseases in child care centers should consider clustering of pathogens or factors promoting transmission within centers that may result in variability between centers.

Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis.

OBJECTIVE: To determine if bronchodilators are efficacious in treating bronchiolitis. DATA SOURCES: A search of bibliographic databases (MEDLINE, Excerpta Medica, and Reference Update) for bronchiolitis and albuterol or ipratropium bromide, or adrenergic agents or bronchodilator agents. Reference lists were also used. STUDY SELECTION: Randomized, placebo-controlled trials of bronchodilator treatment in bronchiolitis were selected by 2 investigators. Fifteen of 89 identified publications met the selection criteria. DATA EXTRACTION: Investigators independently abstracted data for 3 outcomes: clinical score, oxygen saturation, and hospitalization. Clinical score was measured as a dichotomous variable (score +/- improved) or continuous variable (average score). DATA SYNTHESIS: For primary analysis, data were pooled from 8 trials of children with first-time wheezing. The effect size for average score was -0.32 (95% confidence interval [CI], -0.54 to -0.11; P < .01), favoring treatment; the relative risk for score +/- improved was 0.76 (95% CI, 0.60 to 0.95; P = .02), favoring treatment. Bronchodilators had no effect on hospitalization (relative risk, 0.85; 95% CI, 0.47 to 1.53; P = .58), but co-interventions may have been administered prior to this outcome. The results for oxygen saturation were too varied to allow pooling of the results. Secondary analyses were performed on 4 outpatient trials of children with first-time wheezing, 7 trials in which only nebulized beta-agonists were used, and on all 15 trials identified. The results were similar, but the data varied more. CONCLUSION: Bronchodilators produce modest short-term improvement in clinical features of mild or moderately severe bronchiolitis.

Ectopic prostatic tissue in urethra.

Ectopic prostatic tissue in the urethra is an uncommon lesion. It appears more often in young males. The common presenting symptoms are hematuria or hemospermia. It is a benign lesion, and transurethral fulguration is believed to be adequate treatment.

Disseminated bacille Calmette-Guérin infection in an infant with a novel deletion in the interferon-gamma receptor gene.

Six weeks after receiving BCG vaccination, a Canadian aboriginal infant presented with suspected sepsis, lymphadenopathy and hepatosplenomegaly. Lymph node biopsy revealed macrophages filled with acid-fast bacilli. Mycobacterium bovis was cultured from tissue specimens and there was evidence of concomitant cytomegalovirus disease. The infant died of disseminated BCG infection. A novel deletion at nucleotide 165 in the interferon-gamma receptor (IFN-gammaR1) was identified. The incidence of this mutation in the aboriginal population and the impact on the heterozygous state are unknown.

Cyfra 21-1. A new potential tumor marker for squamous cell carcinoma of head and neck.

OBJECTIVE: Evaluation of Cyfra 21-1 (cytokeratin fraction 21-1) in squamous cell carcinoma of the head and neck. DESIGN: Prospective study. PATIENTS: Serum Cyfra 21-1 concentration was measured in 250 samples from patients with squamous cell carcinoma of head and neck, patients with benign tumors of head and neck, healthy control subjects, and patients in remission from squamous cell carcinoma of head and neck. RESULTS: Cyfra 21-1 concentration was elevated in 60% of the new patients with squamous cell carcinoma but only in 8% of patients with benign tumors and 3.5% of the healthy controls. At a cutoff of 1.3 ng/mL, the sensitivity of the test was 60%, the specificity was 94%, positive predictive value was 75%, and negative predictive value was 89%. The marker levels tended to follow the clinical course of the disease and were useful for therapy monitoring. Cyfra 21-1 levels were in good correlation with the tumor stage expressed by the local (T) and the lymphatic spread (N) and were inversely correlated with histologic grade, eg, higher in poorly differentiated carcinoma than in well-differentiated squamous cell carcinoma. CONCLUSION: Cyfra 21-1 evaluation in head and neck squamous cell carcinoma is worthwhile for performance of an ample study that will prove and establish its routine use.

Bronchodilators for bronchiolitis.

OBJECTIVES: Bronchiolitis is an acute, highly communicable lower respiratory tract infection. Bronchodilators are commonly used in the management of bronchiolitis in North America, but not in the United Kingdom. The objective of this review was to assess the effects of bronchodilators for bronchiolitis. SEARCH STRATEGY: We searched MEDLINE, EMBASE, Reference Update, reference lists of articles, and the files of two of the authors up to June 1998. SELECTION CRITERIA: Randomised trials comparing bronchodilators with placebo in the treatment of bronchiolitis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Unpublished data were requested from authors when necessary. MAIN RESULTS: In eight trials with 394 children, 46% demonstrated an improved clinical score with bronchodilators compared to 75% with placebo (odds ratio for no improvement 0.29, 95% confidence interval 0.19 to 0.45). However, the inclusion of studies that enrolled people with recurrent wheezes may have biased these results in favour of bronchodilators. Bronchodilator recipients did not show improvement in measures of oxygenation, the rate of hospitalisation (18% versus 26%, odds ratio 0.70, 95% confidence interval 0.36 to 1.35) or duration of hospitalisation (weighted mean difference 0.12, 95% confidence interval -0.3 to 0.5). REVIEWER'S CONCLUSIONS: Bronchodilators produce modest short-term improvement in clinical scores. This small benefit must be weighed against the costs of these agents.

Glucocorticoids for croup.

BACKGROUND: Since the last meta-analysis in 1989, a number of randomised trials on the benefit of glucocorticoids have been published, resulting in an increasing interest in the use of glucocorticoids to treat outpatients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup, to examine the effectiveness of glucocorticoids in these patients, and to identify areas of uncertainty for future research. OBJECTIVES: To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY: We searched The Cochrane Controlled Trials Register, MEDLINE (January 1966 to August 1997) and Excerpta Medica/EMBASE (January 1974 to August 1997). We also contacted (by mail) authors of identified croup trials published in the last five years to inquire about other trials, published or unpublished. SELECTION CRITERIA: Meta-analysis of randomised controlled trials that examine the effectiveness of glucocorticoid treatment in children with croup. DATA COLLECTION AND ANALYSIS: Data were extracted using a structured form, which captured patient status (inpatient or outpatient), intervention and control, with the name of the drug, route of administration and dose. Data were also collected on the primary outcome measures comprised of a clinical croup score at baseline (as well as any other subsequent assessment times), length of stay (hours), patients status improved (yes/no), and use of co-interventions. The quality of the trials was assessed using empirically derived items that involved scales and components. Two researchers (TPK, MA) then selected studies as being potentially relevant based on a review of the titles and abstracts, if available. The complete text of these studies was then retrieved. All studies that had been retrieved were reviewed independently by two reviewers (AS, TPK). Data were extracted by one reviewer (MA) and checked for accuracy by a second reviewer (TPK). Two observers independently assessed quality (MA, JK), and inter rater agreement was measured by the intra class correlation. Differences were resolved by consensus. MAIN RESULTS: Twenty-four studies were deemed relevant for inclusion (N=2221). Glucocorticoid treatment was associated with an improvement in the croup severity score at 6 hours with an effect size of -1.0 (95% confidence interval -1.5 to -0.6) and at 12 hours -1.0 (-1.6 to -0. 4); at 24 hours this improvement was no longer significant (-1.0, -2. 0 to 0.1). There was a decrease in the number of adrenaline treatments needed in children treated with glucocorticoids: a decrease of 9% (95% confidence interval 2 to 16%) among those treated with budesonide and of 12% (4 to 20%) among those treated with dexamethasone. There was also a decrease in the length of time spent in accident and emergency (-11 hours, 95% confidence interval -18 to 4 hours), and for inpatients hospital stay was reduced by 16 hours (-31 to 1 hour). Publication bias seems to play a part in these results. REVIEWER'S CONCLUSIONS: Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment. Fewer co-interventions are used and the length of time spent in hospital is decreased in patients treated with glucocorticoids.

The effectiveness of glucocorticoids in treating croup: meta-analysis.

OBJECTIVE: To determine the effectiveness of glucocorticoid treatment in children with croup. DESIGN: Meta-analysis of randomised controlled trials that examine the effectiveness of glucocorticoid treatment in children with croup. MAIN OUTCOME MEASURES: Score on scale measuring severity of croup, use of cointerventions (adrenaline (epinephrine), antibiotics, or supplemental glucocorticoids), length of stay in accident and emergency or in hospital, and rate of hospitalisation. RESULTS: Twenty four studies met the inclusion criteria. Glucocorticoid treatment was associated with an improvement in the croup severity score at 6 hours with an effect size of -1.0 (95% confidence interval -1.5 to -0.6) and at 12 hours -1.0 (-1.6 to -0.4); at 24 hours this improvement was no longer significant (-1.0, -2.0 to 0.1). There was a decrease in the number of adrenaline treatments needed in children treated with glucocorticoids: a decrease of 9% (95% confidence interval 2% to 16%) among those treated with budesonide and of 12% (4% to 20%) among those treated with dexamethasone. There was also a decrease in the length of time spent in accident and emergency (-11 hours, 95% confidence interval -18 to 4 hours), and for inpatients hospital stay was reduced by 16 hours (-31 to 1 hour). Publication bias seems to play a part in these results. CONCLUSIONS: Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment. Fewer cointerventions are used and the length of time spent in hospital is decreased in patients treated with glucocorticoids.

Beliefs and behaviours of parents regarding antibiotic use by children.

OBJECTIVE: To determine parents' beliefs and behaviours about antibiotic use by their children in the ambulatory setting. DESIGN: Cross-sectional survey, where a self-administered questionnaire was completed by adult caregivers of children before the medical assessment of the child. SETTING: Three paediatric acute care settings (paediatric emergency department [PED], group paediatric practice and after hours walk-in medical clinic). POPULATION STUDIED: Adult caregivers (n=114; 76% mothers, 19% fathers and 4% other caregivers) of children brought for acute care were surveyed. MAIN RESULTS: Forty-one caregivers completed the survey in the PED, 37 in the paediatric office and 36 in the walk-in clinic. They believed that antibiotics were appropriate for ear infections (86%), pharyngitis (77%), bronchitis (49%), sinus colds (20%), cough (12%), colds (8%) and influenza (8%). Sixty-eight per cent of children had received antibiotics in the previous year. Thirteen per cent of caregivers reported previously requesting an antibiotic for their child, 18% believed a previous antibiotic prescription had been unnecessary and 19% had not complied with prescriptions in the past. Concerns about antibiotic use included antibiotic resistance (50%), harm to the immune system (40%), adverse effects (28%) and lack of efficacy (19%). CONCLUSIONS: In this population, parental knowledge and understanding of indications for antibiotics and their adverse effects were good; however, incorrect beliefs and disagreements with physicians did occur. To improve patterns of antibiotic use by children, it will be necessary to understand parents' beliefs, behaviours and information sources better so that misconceptions and disagreements with caregivers can be addressed appropriately.

[Staging of rectal carcinoma by endorectal ultrasonography].

Staging of rectal carcinoma is essential for its management. 23 patients with rectal lesions were examined by endorectal ultrasonography. Of these 19 had rectal carcinoma and in 4 there was an abscess of the rectal wall, previously diagnosed by sigmoidoscopic biopsy. 10 of those with carcinoma were examined by computerized tomography as well, and 10 were operated on. In most cases the staging of rectal carcinoma by endorectal ultrasonography was accurate and compared well with the operative histological results. We conclude that endorectal ultrasonography is the method of choice for staging of rectal carcinoma prior to treatment.