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Two children had unexplained neurologic disease found to be induced by a parent. The Münchausen-by-proxy syndrome should be considered in children whose neurologic dysfunction is atypical and when there is significant underlying psychopathology in the family. The early recognition of neurologic Münchausen-by-proxy syndrome may prevent costly, potentially dangerous, and painful studies.
This paper reviews the opportunities and pitfalls associated with using clay mineralogical analysis in palaeoclimatic reconstructions. Following this, conjunctive methods of improving the reliability of clay mineralogical analysis are reviewed. The Mesozoic succession of NW Europe is employed as a case study. This demonstrates the relationship between clay mineralogy and palaeoclimate. Proxy analyses may be integrated with clay mineralogical analysis to provide an assessment of aridity-humidity contrasts in the hinterland climate. As an example, the abundance of kaolinite through the Mesozoic shows that, while interpretations may be difficult, the Mesozoic climate of NW Europe was subject to great changes in rates of continental precipitation. We may compare sedimentological (facies, mineralogy, geochemistry) indicators of palaeoprecipitation with palaeotemperature estimates. The integration of clay mineralogical analyses with other sedimentological proxy indicators of palaeoclimate allows differentiation of palaeoclimatic effects from those of sea-level and tectonic change. We may also observe how widespread palaeoclimate changes were; whether they were diachronous or synchronous; how climate, sea level and tectonics interact to control sedimentary facies and what palaeoclimate indicators are reliable.
This study evaluated the validity of patient-proxy responses to the Healthcare Needs Scale for Patients with HIV/AIDS. This scale measures environmental and psychosocial support, financial resources, health behaviors, social support, and health management. A sample of 35 patients with HIV/AIDS and their primary caretakers was selected from a hospital inpatient AIDS unit in Baltimore, Maryland, between 1990 and 1992. The significance of discrepancies between the patient and caretaker responses was tested with Wilcoxon's matched pairs/signed ranks test. None of the 19 scale items exhibited a significant Z statistic. It was concluded that the primary caretakers of PWAs can serve as informed proxies and provide accurate information on the patients' healthcare needs.
Because patients with Alzheimer's disease are on a path of declining capacity to give consent, advancement of research with Alzheimer's disease subjects presents challenging and perplexing ethical and legal dilemmas. Although generic regulations for the protection of human subjects apply, special considerations for cognitively impaired dementia subjects have depended on local Institutional Review Boards and relevant state laws and regulations, producing a lack of uniformity regarding encouragement of research and protection of subjects. Discussed are the dilemmas encountered in advancing research with Alzheimer's disease subjects, including (1) issues about informed consent, (2) determination of decision-making capacity (competency), (3) problems in dealing with subjects of mild and fluctuating impairment, and (4) proxy and advance consent measures for severely impaired subjects. Proposed is an agenda of ethical research needs for advancing biomedical research on Alzheimer's disease. Needed are empirical studies concerning recruitment of Alzheimer's disease subjects, the actual processes of informed consent, and the difficulties encountered by researchers, collaborative development of tests for both diagnosing Alzheimer's disease and assessing subjects' capacities to provide informed consent, and exploration of innovative uses of advance and proxy consents for participation in Alzheimer's disease research.
OBJECTIVE: This ecological study assessed the feasibility and predictive ability of readily available educational indicators as proxy measures of school dental treatment needs in York Region elementary school children, Canada. METHOD: Data sources included York Region Dental Health Unit dental screening data (2003-2004); area-based income data from Statistics Canada (2001) based on school address postcodes; grade three and grade six school performance results in reading, writing mathematics and English as a second language (ESL) data (2003-2004) obtained from publicly accessible educational websites. RESULTS: Data analyses included 219 schools. Pearson's correlations showed that schools with a higher percentage of children needing urgent dental treatment had significantly higher proportions of children scoring below provincial averages in all six school performance categories. Hierarchical stepwise multiple linear regression analysis showed that two school performance variables remained in the model after controlling for area-based median family income and ESL variables: the percentage of grade six pupils scoring below the provincial average in writing and the percentage of grade 3 pupils scoring below the provincial average in reading. CONCLUSIONS: The study established the feasibility of using school-level school performance indicators as proxy measures of school-level dental treatment needs. School performance results were good predictors of urgent dental treatment in York Region elementary school children. Further studies are needed using data from other jurisdictions to determine the utility of educational indicators in oral health programs.
OBJECTIVE: To demonstrate the association between various measures of spinal mobility and radiographic damage of the spine in individual patients with ankylosing spondylitis, and to determine whether the assessment of spinal mobility can be a proxy for the assessment of radiographic damage. METHODS: Radiographic damage was assessed by the mSASSS. Cumulative probability plots combined the radiographic damage score of an individual patient with the corresponding score for nine spinal mobility measures. Receiver operating characteristic analysis was performed to determine the cut off level of every spinal mobility measure that discriminates best between the presence and absence of radiographic damage. Three arbitrary cut off levels for radiographic damage were investigated. Likelihood ratios were calculated to explore further the diagnostic properties of the spinal mobility measures. RESULTS: Cumulative probability plots showed an association between spinal mobility measures and radiographic damage for the individual patient. Irrespective of the chosen cut off level for radiographic progression, lateral spinal flexion and BASMI discriminated best between patients with and those without structural damage. Even the best discriminatory spinal mobility assessments misclassified a considerable proportion of patients (up to 20%). Intermalleolar distance performed worst (up to 30% misclassifications). Lateral spinal flexion best predicted the absence of radiographic damage, and a modified Schober test best predicted the presence of radiographic damage. CONCLUSION: This study unequivocally demonstrated a relationship between spinal mobility and radiographic damage. However, spinal mobility cannot be used as a proxy for radiographic evaluation in an individual patient.
The use of standardised mortality ratios (SMRs) as a proxy measure of morbidity for resource allocation purposes in the National Health Service (NHS) has been widely criticised. The small number of deaths from infectious diseases makes it necessary to consider whether there are more appropriate measures. The standardised notification rate (SNR) was compared with the SMR for respiratory tuberculosis and it appears to be a better proxy for morbidity.
OBJECTIVES: To examine the relationship between specific types of morbidity, measured by validated survey questions, and hospital service use and mortality to see if the latter two could act as a proxy in health needs assessment, health service planning, and resource allocation in a typical health district. DESIGN: A postal questionnaire was used to provide information about depression, digestive disorders, musculo-skeletal disorders, obesity, respiratory disease, and hip and knee pain. The questions were from survey instruments that have been widely used to derive information about these conditions. The relationships between the prevalence of these specific types of morbidity and appropriate admission and mortality rates were explored using linear regression and Pearson correlation analysis. SETTING: The population of Rotherham health district, England. SUBJECTS: A simple random sample of the residents of each of the 22 electoral wards in Rotherham health district. RESULTS: Responses were obtained from 78% of the 5000 sampled (82% after excluding people who had moved house or died). Significant, positive correlations were found between the prevalence of respiratory disease and the hospital admission and mortality rates for respiratory problems (r = 0.68, p < 0.01 and r = 0.54, p < 0.01) and the prevalence of depression and the admission rate for depression (r = 0.52, p < 0.05). No such relations were found for digestive disease, musculo-skeletal disease, and obesity. For the conditions examined here, hospital service use was a more useful measure than mortality. CONCLUSIONS: Only two diseases (respiratory disease and depression) out of the seven diseases or procedures investigated showed a positive correlation between hospital admission and disease prevalence. But even for these two, the correlations explained less than 50% of the variance. Caution must be exercised when hospital service use is being considered as a proxy for morbidity.
Munchausen's syndrome by Proxy is a well-described entity that may not always be immediately considered in a complicated case. We describe this syndrome being portrayed through the guise of gastrointestinal bleeding in a 15 month old male and discuss not only the difficulty involved in solidifying this diagnosis but also the consequences that may occur should this diagnosis not be entertained. Failure to diagnose Munchausen's syndrome by proxy often results from failure to consider the diagnosis. These cases frequently have specific characteristics that allow seasoned clinicians to suspect the diagnosis. Once the diagnosis is considered, it is crucial to take steps to protect not only the index patient but also siblings who not infrequently are also recipients of this life threatening form of child abuse.
In order to determine whether simplified indicators for usual consumption of selected food groups, specifically those derived from either the percentage of the number of daily portions, the percentage of total daily weight consumed, or both, could serve as proxies for the conventional expression of daily energy intake, these indicators were computed and compared from food-frequency data in a data set. Food consumption was reported in frequency categories and portion sizes per month, per week, or per day, and the cumulative sum was divided by 365 to provide a daily average. The survey was done in the township of Santa Cruz and three hamlets of a rural county seat in Guatemala. Data from food-frequency questionnaires from 269 individuals (55 men and 214 women aged 16 to 86 years) were analyzed. For foods of plant origin, the percentage of total energy, percentage of total food weight, and percentage of total number of portions consumed showed low correlations (r < .45). When subdivided into specific foods and food groups (fruits and vegetables, red meat, etc.), marked differences were revealed across sites and among different indicators of consumption. Despite the simplicity of calculation, neither the percentage of weight of food in a group nor the percentage of portions consumed could serve reliably as proxies for their contributions to the percentage of total energy in this rural population in Guatemala.
BACKGROUND: Health studies sometimes rely on postal code location as a proxy for the location of residence. This study compares the postal code location to that of the street address using a database from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACHCopyright ). Cardiac catheterization cases in an urban Canadian City were used for calendar year 1999. We determined location in meters for both the address (using the City of Calgary Street Network File in ArcView 3.2) and postal code location (using Statistic Canada's Postal Code Conversion File). RESULTS: The distance between the two estimates of location for each case were measured and it was found that 87.9% of the postal code locations were within 200 meters of the true address location (straight line distances) and 96.5% were within 500 meters of the address location (straight line distances). CONCLUSIONS: We conclude that postal code locations are a reasonably accurate proxy for address location. However, there may be research questions for which a more accurate description of location is required.
Both the State of New York and Victoria, Australia, have enacted health care proxy legislation in the past two years. The provisions are similar, although there is some difference in detail. This article reviews and compares the health proxy laws in each of these two states.
Low language ability and response bias are frequently cited as impediments to valid responding to items on interview schedules. Structured interviews with a random sample of 154 adults with mental retardation showed that around two thirds of respondents were either unable to respond or exhibited response bias. There was a significant difference in scores on the Adaptive Behavior Scale between those who exhibited response bias and those who did not. In cases of nonresponse or response bias, the substitution of the respondent with a proxy respondent has been proposed as an alternative method of gathering subjective data. In this study concordance between individuals' responses and those of proxies was low on a subjective measure and high on an objective scale.
OBJECTIVE: Informed consent for surgical procedures requires that the procedures are explained and that the patient understands the procedures and risks and agrees to undergo them. Proxy consent occurs when an individual is provided with the legal right to make decisions on behalf of another. This study was conducted to determine how surgeons communicate information to obtain an informed proxy consent, and to investigate how that information is received and processed by surrogates responsible for providing such consent. STUDY DESIGN: Twenty English-speaking parents or legal guardians and 5 surgeons in an urban pediatric hospital were interviewed before, and 2 to 4 weeks after, the surgical procedure. In addition, the interview between the surgeon and surrogate, when consent was obtained, was audiotaped and subsequently analyzed. Semistructured interviews were used to elicit the motivations and influences on the surrogates to consent to the procedure. The same methodology was used to elicit the corresponding impressions of the surgeons. The data were analyzed using descriptive statistics and crosstabulations. RESULTS: Demographic data did not influence the results. Although there was concordance between the surrogate's understanding of the procedure and the surgeon's impression of this understanding, only 3 of 17 surrogates could recall any specifics of the explained procedure. Contrary to the stated belief of surgeons, surrogates consulted with a variety of others, including medical and paramedical professionals, family members, and spiritual leaders. CONCLUSIONS: Communication plays an important role within the surrogate-surgeon dyad. Psychologic variables such as expectations, and the perception of both the surrogates and the surgeons, influence the amount of information that is proffered and the manner in which it is received. Improved communication may be achieved by use of visual aids, discussion of anesthesia and the postoperative course, recognition of the circumstances around the discussion, such as timing and location of the discussion, and personalization of the discussion.
OBJECTIVE: To draw pediatrician's and healthcare worker's attention to the Munchausen syndrome by proxy, a serious kind of child abuse. PATIENTS AND METHODS: We report the clinical history and the evolution of two patients, based on a review of these patient's files in the Children's Rights Committee of the Hospital da Criança Santo Antônio, for further discussion. The first case reports a 5- year old child that presented difficult-controlling seizures; this case had an excellent prognosis after being examined by several specialists and later on by the Children's Right Committee. The second case reported is a 5-month old infant who presented apnea crisis accompanied by cyanosis and seizures. COMMENT: Munchausen syndrome by proxy is a relatively rare clinical entity, that can be difficult to be diagnosed, leading to unnecessary and potentially harmful diagnostic procedures to the child.
Munchausen syndrome by proxy is the act of one person fabricating or inducing an illness in another to meet his or her own emotional needs through the treatment process. The diagnosis is poorly understood and controversial. We report here the case of a 6-year-old boy who presented with possible pneumonia, nausea, vomiting, and diarrhea and whose mother was suspected of Munchausen syndrome by proxy.
Certain social expectations of medicine combine with characteristics of subspecialised technological paediatrics to facilitate the form of child abuse labelled "Munchausen by proxy syndrome". Examining this form of child abuse highlights possible shortcomings of medical practice. The primary medical tasks of diagnosing and curing illness and of preventing suffering are sometimes overridden by other motivations of which doctors may not be fully aware. More open discussion of what motivates health professionals in their work may improve medical practice and lead to a reduced incidence of Munchausen by proxy syndrome.
A new variant of Munchausen Syndrome by Proxy (MSbP) case is presented here: Munchausen by Adult Proxy (MSbAP). The article discusses the case of a man (publicly known as the "Gasoline Injector") who is serving a 46-year jail term for attempted murder and manslaughter. His behavior is reminiscent of MSbP but his victims were two female adults, and his cell mate (on whom he repeated his actions). A description is given in terms of egosyntonic irresistible pathological impulses involving sexual objects. A common ground is proposed for paraphilias, Munchausen syndrome, MSbP and MSbAP.