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Munchausen Syndrome by Proxy has been recognised for almost two decades. This review considers the definition, clinical features, consequences (to both victim and perpetrator), diagnosis and outcome of the syndrome.
The major histocompatibility complex (MHC) class I (MHC-I) antigen presentation system is responsible for the cell-surface presentation of self-proteins and intracellular viral proteins. This pathway is important in screening between self, and non-self or infected cells. In this pathway, proteins are partially degraded to peptides in the cytosol and targeted to the cell surface bound to an MHC-I receptor protein. At the cell surface, T cells bypass cells displaying self-peptides but destroy others displaying foreign antigens. Cells contain several isoforms of the proteasome, but it is thought that the immunoproteasome is the major form involved in generating peptides for the MHC-I pathway. How all intracellular proteins are targeted for MHC-I processing is unclear. Oxidative stress is experienced by all cells, and all proteins are exposed to oxidation. We propose that oxidative modification makes proteins susceptible to degradation by the immunoproteasome. This could be called the protein oxidation and immunoproteasome or 'PrOxI' hypothesis of MHC-I antigen processing. Protein oxidation may, thus, be a universal mechanism for peptide generation and presentation in the MHC-I pathway.
The purpose of this study was to determine the association between drive for thinness (DT) and adaptations to energy deficiency in exercising women. This observational study evaluated psychometric and metabolic factors in sedentary (n=9, 27.9+/-2.0 yr) and exercising women (n=43, 24.0+/-1.1 yr). Volunteers were retrospectively grouped according to exercise status (sedentary or exercising) and a DT score of normal (sedentary or exercising) or high (exercising only). Resting energy expenditure (REE) and metabolic hormones (triiodothyronine, (TT3), ghrelin, leptin, insulin) were measured repeatedly over a 2-3 month period. The DT subscale successfully discriminated the groups based on energy status. Although the groups did not differ in body weight, the high DT group exhibited adaptations to chronic energy deficiency, including a REE below 90% of their predicted REE (86+/-3.0%), significantly lower TT3 levels and significantly higher ghrelin levels than the normal DT groups. Since energy deficiency plays a causal role in the Female Athlete Triad, DT may serve as a proxy indicator of underlying energy deficiency and may be useful for identifying individuals at risk for Triad disorders prior to the development of serious clinical sequelae.
This article describes potentially pathogenic behavior in youth sports. It delineates the four stages of achievement by proxy distortion (ABPD) behavior and attempts to raise awareness of that behavior and to facilitate communication among sports medicine and psychiatry professionals of the potential for exploitation and abuse of children and adolescents by parents, mentors, coaches, and the systems that nurture and develop these children. Information is presented to distinguish motivations behind normal parenting from those that lead to risky sacrifice, objectification of the child, and potential abuse. Distinct abuse stages of ABPD are described. The authors identify "red flags" that indicate distorted views and potentially harmful behavior toward children.
The association between socio-economic status (SES) and untreated hypertension varies according to a country's level of development and racial/ethnic group. We sought to confirm this variation in women from China and the United States (US) as well as to investigate the impact of SES on several mediating risk factors. We also investigate the extent to which SES explains racial/ethnic differences in untreated hypertension in the US. We used cross-sectional data from 1814 non-pregnant women in China (China Health and Nutrition Survey (CHNS), 1997) and 3266 non-pregnant women in the United States (National Health and Nutrition Examination Survey (NHANES III), 1988-1994) respectively. A variety of statistical modelling techniques was used to predict untreated hypertension as a function of several mediating factors and to simulate the impact of changes in SES. The age-adjusted prevalence of untreated hypertension was significantly higher (p<0.01) for low-income White and Black women compared to Mexican American or Chinese women. Untreated hypertension was not significantly associated with income or education in Mexican Americans or women in China. Obesity and light physical activity had the largest mediating effect on the association between SES and untreated hypertension for all racial/ethnic groups. However, this effect was not as strong as the proxy effect of income and education. SES did not completely explain racial/ethnic differences in hypertension in the US. While SES was more strongly associated with hypertension in Blacks than Whites, Blacks were still 1.97 (95% CI 1.47-2.64) times more likely to have untreated hypertension than Whites after adjusting for SES differences. The association between SES and untreated hypertension varied by country and racial/ethnic group. An important explanation for this variation was the differential effect of SES on mediating risk factors. SES disparities between Whites and Blacks in the US partly explain differences in the prevalence of untreated hypertension between these racial/ethnic groups.
BACKGROUND: The standard methodological approach for evaluating social cognitive theories when predicting physical activity behavior is the passive prospective/longitudinal survey design. Although this design is logical, a cross-sectional design may be a cost-effective alternative if the relationships between social cognitive constructs and physical activity are relatively stable. The purpose of this study was to evaluate the utility of a concurrent measure of physical activity used in a cross-sectional design in comparison to the standard prospective measure. METHODS: This study included two 6-month prediction time-periods, between 1997 and 1998, for the purpose of analysis replication, and the theory of planned behavior, the transtheoretical model, protection motivation theory, and social cognitive theory as the models of interest in a population sample (N = 703). RESULTS: Results showed trivial (69% of tests; q < 0.10) to small (31% of tests; q = 0.11-0.18) differences in the correlations between social cognitive constructs and vigorous physical activity occur when using a cross-sectional or prospective design. The cross-sectional design estimated slightly larger coefficients than the prospective design. CONCLUSIONS: It appears that a measure of concurrent physical activity included in a cross-sectional design can act as a reasonable proxy measure of future behavior measured in a passive prospective/longitudinal design. These findings support the use of cross-sectional designs when researchers seek a standard correlational investigation of physical activity and social cognitive constructs with the possibility that coefficients may be slightly biased upwards.
Over a three-year period, we have seen in consultation four children whose mothers cited complaints referable to every organ system and which had persisted for many years. The parents had consulted a total of 99 physicians in eight states. Absence from school ranged from 40 to 200 days a year. Physical examinations of all patients and extensive and repeated laboratory studies were normal. On psychiatric examination the mothers exhibited paranoid thinking and a conviction of serious medical illness in their child which approached delusional proportions. They resisted psychiatric consultation and refused psychotherapy. The mother-child relationship was remarkably symbiotic, the two teen-age patients essentially voicing complaints which were indistinguishable from those reported by their mothers. The fathers invariably supported their wives' concerns. Subsequently, parents and children left treatment, continuing to "doctor shop." Long-standing multisystem complaints in a child with normal growth and maturation are incompatible with any known significant organic disease, but suggest a serious emotional problem within the family. Further, parents who take such children from doctor to doctor are frequently disturbed themselves and may use an offspring as a proxy patient. An accurate diagnosis depends on careful history-taking from parents, patient, health professionals, and schools.
The distribution and abundance of benthic foraminifera and a range of elements have been analysed in six long cores (up to 10 m long) from the Bilbao estuary, N. Spain, to document environmental transformation of this estuarine ecosystem and to determine sediment contamination levels. Three different environmental zones could be distinguished in the recent sedimentary record based on its microfaunal and geochemical contents. Initially, a pre-industrial zone containing very abundant and diverse foraminiferal assemblages together with baseline metal levels. Secondly, an older industrial zone exhibiting co-existence of abundant and diverse foraminiferal assemblages with high concentrations of metals. Finally, a younger industrial zone with extreme concentrations of metals and barren of indigenous foraminifera. This environmental transformation has been caused by the discharge of untreated domestic and industrial effluents during the last 150 years. The occurrence of foraminifera in the two industrial zones and along the estuary is not related to defined levels of metals, and this seems to confirm oxygen limitation as the key factor to explain complete estuarine defaunation during deposition of the younger industrial zone (period 1950-2000). Effectiveness of current regeneration schemes could be assessed using microfaunal and geochemical proxies as environmental quality indicators.
Analysis of 170 pollen assemblages from surface samples in eight vegetation types in the Florida Everglades indicates that these wetland sub-environments are distinguishable from the pollen record and that they are useful proxies for hydrologic and edaphic parameters. Vegetation types sampled include sawgrass marshes, cattail marshes, sloughs with floating aquatics, wet prairies, brackish marshes, tree islands, cypress swamps, and mangrove forests. The distribution of these vegetation types is controlled by specific environmental parameters, such as hydrologic regime, nutrient availability, disturbance level, substrate type, and salinity; ecotones between vegetation types may be sharp. Using R-mode cluster analysis of pollen data, we identified diagnostic species groupings; Q-mode cluster analysis was used to differentiate pollen signatures of each vegetation type. Cluster analysis and the modern analog technique were applied to interpret vegetational and environmental trends over the last two millennia at a site in Water Conservation Area 3A. The results show that close modern analogs exist for assemblages in the core and indicate past hydrologic changes at the site, correlated with both climatic and land-use changes. The ability to differentiate marshes with different hydrologic and edaphic requirements using the pollen record facilitates assessment of relative impacts of climatic and anthropogenic changes on this wetland ecosystem on smaller spatial and temporal scales than previously were possible.
Azithromycin (Zithromax, Pfizer Inc., New York, NY, USA) is effective in the control of blinding trachoma. Community-based azithromycin treatment is recommended by the World Health Organization as part of a multipronged strategy aimed at the global elimination of binding trachoma by the year 2020. Paediatric trachoma is treated with azithromycin according to weight at a target dosage of 20 mg/kg. However, conventional weight-based treatment may be problematic in the field due to the logistical difficulties associated with weight scales. We assessed the accuracy of using height as a proxy for weight to determine azithromycin treatment in 4 countries--Viet Nam, Tanzania, Ghana, and Mali--where mass treatment programmes are underway. Population-based data collected from 1988 to 2000 were analysed using least squares regression. Height treatment schedules were developed for each data set. The accuracy of each schedule was evaluated according to the percentage of children receiving treatment within a dosage range of 20-30 mg/kg, a conservative estimate of the safe and effective treatment range for paediatric trachoma. Using height to determine dose, 89-95% of children would receive a dosage of 20-30 mg/kg. In these populations, height-based treatment is a reliable alternative to conventional weight-based treatment. Methods for developing height schedules presented in this analysis could be applied to other regions and therapeutics.
Some patients consistently produce false stories and fabricate evidence, so causing themselves needless hospital investigations and operations. Here are described parents who, by falsification, caused their children innumerable harmful hospital procedures--a sort of Munchausen syndrome by proxy.
In a cluster of illness reported among students at an elementary school parents mentioned many signs and symptoms including headache, pallor, dark circles under the eyes, nausea, and vomiting--which they attributed to exposure to recurrent leaks of natural gas at the school. It is likely that the parents spread among themselves the notion of toxic exposure at the school. A questionnaire revealed no spatial clustering, but increased reports of symptoms were related to intense media coverage. A thorough environmental and epidemiological investigation was negative, there being no evidence of a continuing gas leak or other potential causes. At a strictly biological level, the complaints in this reported "cluster" apparently represented the sporadic occurrence of common childhood illnesses. The possibility of an epidemic from toxic exposure at the school caused intense parental concern and led to a major public health problem. The established term "mass sociogenic illness" seems inapplicable here because complaints did not come principally from the students and the apparent epidemic illness was not transmitted among them. The term "mass sociogenic illness by proxy" is proposed to describe this incident, in which transmission in one group (the parents) resulted in reports of an epidemic in another group (students).
The association between levels of marijuana use and last year dependence is investigated in a nationally representative sample of adolescents and adults, who used marijuana within the last year (n = 9284). Data are aggregated from three surveys (1991-1993) of the National Household Survey on Drug Abuse. A proxy measure of DSM-IV dependence criteria was developed from self-reported symptoms of dependence and drug-related problems. Both frequency and quantity of marijuana use within the last year are linearly associated with the logit of the probability of being dependent on marijuana. The associations vary significantly by age but not gender. Adolescents are dependent at a lower frequency and quantity of use than adults: the differences diverge as level of use increases. Twice as many adolescents as adults who used marijuana near-daily or daily within the last year were identified as being dependent (35% versus 18%). Frequency and quantity of use each retained a unique effect on dependence, but frequency appeared to be more important than quantity in predicting last year dependence. These results provide insight into the processes underlying the age and sex differentials observed in the prevalence of marijuana dependence. The implications of the findings for the epidemiology of marijuana use and dependence are discussed.
PURPOSE: To investigate the reliability of reports of parental smoking by elementary schoolchildren aged 9-13 years, and to identify the correlates of disagreement between student proxy and parent self-reports. METHODS: As part of the evaluation of a school-based heart health promotion program, data on parental smoking status were collected from 1240 student-mother pairs and 898 student-father pairs. RESULTS: Agreement for parental smoking status was 93.1% among student-mother pairs and 86.4% among student-father pairs. Among student-mother pairs, reports by students aged 9 years were more likely to disagree with mothers' self-reports than those of older children (odds ratio (OR) = 3.1). Among student-father pairs, the only significant correlate of disagreement was living in a single-parent family headed by the mother (OR = 2.6). CONCLUSIONS: Children 10-years or older can provide reliable reports of the smoking status of cohabiting parents.
This paper examines the validity of using ecologic measures of socioeconomic status as proxies for individual-level measures in the study of population health. Based on a representative 5% sample of households in a Canadian province, the study integrated three sources of information: administrative records of individual health care utilization, records of deaths and 1986 census records which contained information on household income and average neighbourhood income. Thirteen measures of health status were developed from these sources of information. The hypothesis that risk estimates derived from ecologic income measures will be attenuated relative to estimates obtained from household income was not supported. These results provide evidence for the use of ecologic-level measures of income in studies which do not have access to individual-level income measures.
OBJECTIVES: We designed a series of experiments to determine whether expiratory water condensate (PconCO2) can be used as a proxy for mixed expired gas collection. METHODS: In 18 adult mechanically ventilated patients with ARDS (40 samples), simultaneous collections of arterial blood, expiratory water trap condensate, mixed expired gas, and minute ventilation were used to calculate VCO2 and VD/VT. To assess the effect of temperature, a constant gas flow (PCO2 10-30 mm Hg) was bubbled through water at temperatures of 19.5-37 degrees C. Gas and water samples were collected, immediately analyzed for PCO2, and a temperature correction factor was calculated. A lung model was constructed using a 5 L anesthesia bag connected to a mechanical ventilator with a heated humidifier. Temperature at the Y-piece was set to approximately 37 degrees C and CO2 was injected into the bag to establish an end-tidal PCO2 of 20-70 mm Hg. After equilibration, condensate was collected, PCO2 was measured, and the temperature-corrected PCO2 was compared to PECO2. The capnogram at points along the expiratory limb circuit was used to evaluate gas mixing. RESULTS: There was an over-estimation of PECO2 by PconCO2 (p < 0.001) for the patient data, resulting in an underestimation of VD/VT (p < 0.001) and an overestimation of VCO2 (p < 0.001). The temperature correction factor for PCO2 in water was -0.010 (about half of the factor used for whole blood). The bias between temperature-corrected PconCO2 and PECO2 was 0.3 +/- 3.2 mm Hg in the lung model. Mixing in the expiratory limb was poor, as evaluated by the capnogram. CONCLUSIONS: Even with temperature correction, we failed to precisely predict PECO2 from PconCO2. For measurement of VD/VT and VCO2, we do not recommend methods that use PconCO2.
Recent evidence suggests potential associations between birthweight and disease in later life. For resource or other reasons recorded birthweight may be unavailable to researchers who have access to uniquely relevant outcome data. The present study examined the validity of parental recall of birthweight. Parents of 1015 males and females aged 12 and 15 years participating in the Young Hearts Study (a cluster random sample of 1015 males and females aged 12 and 15 years from post-primary schools in Northern Ireland) completed a questionnaire which included a question about their child's birthweight. The answer provided was compared with recorded birthweight obtained from archived computerised child health records with a cut-off point for inaccurate reporting set at +/- 227 g (1/2 lb). The influence of social class and weight at birth on accuracy of recall was also determined. A total of 84.8% of parents accurately recalled their child's birthweight to within 227 g. Parents from non-manual occupation social classes recalled birthweight more accurately than those from manual occupation social classes (88.0 vs. 82.6% accurate: chi2 = 4.81, p = 0.03). Parents of low birthweight infants tended to recall their birthweight less accurately than parents of normal weight infants: 76.1% accurate compared to 86.1% accurate: chi2 = 3.54, p = 0.06. Parents of high birthweight infants recalled their birthweight less accurately than parents of normal weight infants: 78.5% accurate: chi2 = 3.94, p = 0.05. In conclusion, parentally recalled birthweight may be a suitable proxy for recorded birthweight for population based research into disease in childhood and adolescence.
Central nervous system (CNS) tumours account for 20% of childhood cancers. Survivors often experience severe physical, neuropsychological and social sequelae of the disease and its treatment. Health status assessment in these individuals is an essential clinical outcome measure, yet little consensus exists regarding the optimum methodology. The influence of proxy respondents (parents, physiotherapists and doctors) and mode of administration (home and clinic) in which assessments is performed has been evaluated in a cohort of 37 survivors of childhood CNS tumours. A health-related quality of life (HRQOL) questionnaire, incorporating the Mark II and III Health Utilities Indices, was completed at home and in clinic by patients and parents. Doctors and physiotherapists completed this questionnaire plus Lansky Play-Performance and Karnofsky Performance scores. No significant differences between raters for single attribute scores occurred either at home or in clinic, although a wide range of agreement (kappa = 0.05-1.00, percentage agreement 53-100%) between observers was revealed. Most agreement occurred between parents and patients: this was greatest on home completion (kappa = 0.48-1.00, percentage agreement 53-100%). Doctors and physiotherapists agreed less on subjective attributes (emotion, cognition and pain). Better if responses were classified as normal and abnormal. Inter-observer agreement was greater for the HRQOL questionnaire than for Karnofsky and Lansky scores. Home completion of questionnaires provides a reliable, acceptable and convenient method of assessing health status.