Risk factors for positional plagiocephaly and appropriate time frames for prevention messaging

OBJECTIVE

To determine potential risk factors for developing positional plagiocephaly in infants seven to 12 weeks of age in Calgary, Alberta.

METHODS

A prospective cohort design was used. Healthy term infants (n=440), seven to 12 weeks of age, from well-child clinics at four community health centres in Calgary, Alberta were assessed by the primary author and a registered nurse research assistant using Argenta's plagiocephaly assessment tool. Parents completed a questionnaire surveying risk factors.

RESULTS

The incidence of positional plagiocephaly was estimated to be 46.6%. The following risk factors were identified using multiple logistic regression: right-sided head positional preference (OR 4.66 [95% CI 2.85 to 7.58]; P<0.001), left-sided head positional preference (OR 4.21 [95% CI 2.45 to 7.25]; P<0.001), supine sleep position (OR 2.67 [95% CI 1.58 to 4.51]; P<0.001), vacuum/forceps assisted delivery (OR 1.88 [95% CI 1.02 to 3.49]; P=0.04) and male sex (OR 1.55 [95% CI 1.00 to 2.38]; P=0.05).

CONCLUSION

Advice to vary infants' head positions needs to be communicated to parents/guardians well before the two-month well-child clinic visit. This could occur in the prenatal period by prenatal care providers or educators, or during the neonatal period by postpartum and public health nurses. Prevention education may be emphasized for parents/guardians of male infants and infants who have had assisted deliveries.

The incidence of positional plagiocephaly: a cohort study

OBJECTIVE

The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada.

METHODS

A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argenta's (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly.

RESULTS

Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form.

CONCLUSIONS

To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argenta's plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argenta's plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

"I really wanted to be able to contribute something": understanding health science student motivations to create meaningful global health experiences

BACKGROUND

Global health is an area of increasing interest among health professionals, students and educators. This study aims to explore students' motivations and experiences with an undergraduate global health research program in low and middle-income countries and to assess student learning and areas for program improvement.

METHODS

All students participating in the Global Health Research Program at the University of Calgary in the summer of 2009 were asked to participate in the study (n=11). In-depth interviews were conducted with students prior to departure and upon their return. Discourse analysis was used to identify interpretive repertoires and to determine how the use of repertoires improves our understanding of students' experiences.

RESULTS

Prior to departure, students were highly motivated to "give back" to host communities. Upon return, students felt that their experience had been more about "building relationships" with others than individual contributions to hosts.

DISCUSSION

Students' altruistic motivations dominated the discourse, and most students incorporated core concepts from a preparation course only after their international experience. Extensive preparation, supervision and follow-up support can mitigate many of the risks of short-term global health experiences while providing a safe opportunity for significant learning.

A qualitative pilot study of food insecurity among Maasai women in Tanzania

BACKGROUND

Food insecurity is an ongoing threat in rural sub-Saharan Africa and is complicated by cultural practices, the rise of chronic conditions such as HIV and land use availability. In order to develop a successful food security intervention program, it is important to be informed of the realities and needs of the target population. The purpose of this study was to pilot a qualitative method to understand food insecurity based on the lived experience of women of the Maasai population in the Ngorongoro Conservation Area of Tanzania.

METHODS

Short semi-structured qualitative interviews with 4 Maasai women.

RESULTS

FOOD INSECURITY WAS PRESENT IN THE MAASAI COMMUNITY: the participants revealed that they did not always have access to safe and nutritious food that met the needs of themselves and their families. Themes that emerged from the data fell into three categories: Current practices (food sources, planning for enough, food preparation, and food preservation), food Insecurity (lack of food, emotions, coping strategies, and possible solutions), and division (co-wives, food distribution, and community relationships).

CONCLUSION

This pilot study suggested the presence of food insecurity in the Maasai community. Larger sample studies are needed to clarify the extent and severity of food insecurity among this population. Having a detailed understanding of the various aspects of the food insecurity lived experience could inform a targeted intervention program.

Comparing the treatment response of great saphenous and small saphenous vein incompetence following surgery and endovenous laser ablation: a retrospective cohort study

Objective

Many venous trials mix patients with great saphenous vein (GSV) and small saphenous vein (SSV) diseases. There is no evidence that both respond similarly to treatment and our aim was to test this assumption.

Method

This cohort study compares patients with isolated GSV and SSV incompetence following treatment with open surgical ligation or endovenous laser ablation (EVLA). Outcomes included: quality of life (QoL; Aberdeen Varicose Vein Questionnaire [AVVQ]; Short Form 36 [SF36]; Euroqol [EQ5D]; and Venous Clinical Severity Score [VCSS]).

Results

A total of 370 patients with no differences in baseline QoL, underwent treatment. Despite equivalent morbidity, SSV sufferers had a lower VCSS ( P < 0.001). Following surgery, SSV patients scored higher (worse) on AVVQ ( P = 0.045) than GSV sufferers, but lower (better) following EVLA ( P = 0.042).

Conclusion

The morbidity associated with SSV incompetence is greater than suggested by its clinical severity and responds differently following treatment to that of the GSV. Trials should consider patients with GSV and SSV reflux separately. EVLA may offer additional benefits to SSV sufferers.

Clinical and technical outcomes from a randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Background

This report describes the clinical effectiveness and recurrence rates from a randomized trial of endovenous laser ablation (EVLA) and surgery for varicose veins.

Methods

Some 280 patients were randomized equally using sealed opaque envelopes to two parallel groups: surgery and EVLA. Inclusion criteria included symptomatic disease secondary to primary, unilateral, isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein (GSV). Outcomes were: technical success, recurrent varicose veins on clinical examination, patterns of reflux on duplex ultrasound examination, and the effect of recurrence on quality of life, assessed by the Aberdeen Varicose Vein Questionnaire (AVVQ). Assessments were at 1, 6, 12 and 52 weeks after the procedure.

Results

Initial technical success was greater following EVLA: 99·3 versus 92·4 per cent (P = 0·005). Surgical failures related mainly to an inability to strip the above-knee GSV. The clinical recurrence rate at 1 year was lower after EVLA: 4·0 versus 20·4 per cent (P &lt; 0·001). The number of patients needed to treat with EVLA rather than surgery to avoid one recurrence at 1 year was 6·3 (95 per cent confidence interval 4·0 to 12·5). Twelve of 23 surgical recurrences were related to an incompetent below-knee GSV and ten to neovascularization. Of five recurrences after EVLA, two were related to neoreflux in the groin tributaries and one to recanalization. Clinical recurrence was associated with worse AVVQ scores (P &lt; 0·001).

Conclusion

EVLA treatment had lower rates of clinical recurrence than conventional surgery in the short term. Registration number: NCT00759434 (http://www.clinicaltrials.gov).

Modelling the effect of venous disease on quality of life

Background

A clear understanding of the relationship between venous reflux, clinical venous disease and the effects on quality of life (QoL) remains elusive. This study aimed to explore the impact of venous disease, and assess any incremental direct effect of progressive disease on health-related QoL, with the ultimate aim to model venous morbidity.

Methods

Consecutive patients with venous disease were assessed for inclusion in the study. Patients with isolated, unilateral, single superficial axial incompetence diagnosed on duplex imaging were included. Clinical grading was performed with the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification and Venous Clinical Severity Score (VCSS). Patients completed generic (Short Form 36, SF-36®; EuroQol 5D, EQ-5D™) and disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ) QoL instruments. Multivariable regression modelling was performed, taking account of demographic and anatomical factors, to explore the effect of clinical severity on QoL impairment.

Results

Some 456 patients with C2–6 venous disease were included, along with control data for 105 people with C0–1 disease. Increasing clinical grade corresponded strongly with deterioration in disease-specific QoL (P &lt; 0·001). This could be stratified into three distinguishable groups: C0–1, C2–4 and C5–6 (P &lt; 0·001 to P = 0·006). Increasing clinical grade also corresponded with deterioration in the physical domains of SF-36® (P &lt; 0·001 to P = 0·016), along with EQ-5D™ index utility (quality-adjusted life year) scores (P &lt; 0·001).

Conclusion

Demonstrable morbidity was seen, even with uncomplicated venous disease. The physical impairment seen with venous ulceration was comparable with that seen in congestive cardiac failure and chronic lung disease.

Food provisioning experiences of ultra poor female heads of household living in Bangladesh

Ultra poor women in Bangladesh are especially vulnerable to poverty and food insecurity, and they have generally been excluded from recent improvements in hunger and poverty rates in the country. An examination of the food provisioning narratives of 43 ultra poor female heads of household in Bangladesh was conducted in order to deepen understanding of this obstacle to the country's achievement of the First Millennium Development Goal. All participants were the household's sole income provider, had dependent children, and earned less than $1 USD per day. Women were purposively selected based on occupational group, context, and personal characteristics. Ethnographic interviews were conducted in January and February, 2008. Analysis of women's accounts of their daily food routine revealed chronic and pervasive food insecurity punctuated by acute episodes of absolute food deprivation that resulted from seasonal fluctuations in earnings, rising food prices, illness disrupting work, and healthcare costs. Women's accounts of their daily food provisioning experiences suggested compromises in, and trade-offs between, multiple basic needs as a result of inadequate income. Women were further constrained by social norms and gender roles that influenced their ability to work outside the home. Our method of inquiry led us to construct an organizing framework that extends knowledge of ultra poor women in Bangladesh's complex and multi-sphered experience of poverty and food insecurity. Based on these findings, we propose a strategy called whole person development (WPD), which seeks small adjustments to services, programs, and policies based on leverage points identified through in-depth narratives.

Randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Background

Endovenous laser ablation (EVLA) is a popular minimally invasive treatment for varicose veins. Surgical treatment, featuring junctional ligation and inversion stripping, has shown excellent clinical and cost effectiveness. The clinical effectiveness of both treatments was compared within a randomized trial.

Methods

Some 280 patients were randomized equally into groups receiving either surgery or EVLA. Participants had primary, symptomatic, unilateral venous insufficiency, with isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein. Outcomes included: quality of life (QoL), Venous Clinical Severity Score (VCSS), pain scores and time taken to return to normal function. Owing to the nature of the procedures, blinding was not possible.

Results

Both groups had significant improvements in VCSS after treatment (P &lt; 0·001), which resulted in improved disease-specific QoL (Aberdeen Varicose Vein Questionnaire, P &lt; 0·001) and quality-adjusted life year (QALY) gain (P &lt; 0·001). The pain and disability following surgery impaired normal function, with a significant decline in five of eight Short Form 36 (SF-36®) domains (P &lt; 0·001 to P = 0·029). Periprocedural QoL was relatively preserved following EVLA, leading to a significant difference between the two treatments in pain scores (P &lt; 0·001), six of eight SF-36® domains (P = 0·004 to P = 0·049) and QALYs (P = 0·003). As a result, surgical patients took longer to return to work and normal activity (14 versus 4 days; P &lt; 0·001). Complications were rare.

Conclusion

EVLA was as effective as surgery for varicose veins, but had a less negative impact on early postintervention QoL. Registration number: NCT00759434 (http://www.clinicaltrials.gov).

Randomized clinical trial of co-amoxiclav versus no antibiotic prophylaxis in varicose vein surgery

Background

Wound infection rates of up to 16 per cent are reported following varicose vein surgery and the value of antibiotic prophylaxis in clean surgery remains unclear.

Methods

Some 443 patients undergoing varicose vein surgery randomly received a single prophylactic dose of 1·2 g co-amoxiclav (219 patients) or no antibiotic (224). Patients completed a wound diary on postoperative days 3, 5, 7, 9 and 10 using an adapted ASEPSIS method of wound assessment, and were reviewed after 14 days.

Results

Patients who had prophylaxis had lower ASEPSIS wound scores on days 3, 5 and 7 (P = 0·043, P = 0·032 and P = 0·003 respectively), and lower total ASEPSIS scores (median (interquartile range) 3 (0–9) versus 6 (0–15); P = 0·013). They were less likely to consult their general practitioner (16.0 versus 24·3 per cent; P = 0·040) or to receive postoperative antibiotics (4·7 versus 13·5 per cent; P = 0·002) for wound-related problems. Wound outcomes were worse with higher body mass index (odds ratio (OR) 0·92 (95 per cent confidence interval (c.i.) 0·87 to 0·97); P = 0·005) and current smoking (OR 0·5 (0·3 to 0·9); P = 0·033). Prophylactic antibiotics conferred satisfactory wound healing (OR 2·2 (95 per cent c.i. 1·3 to 3·6); P = 0·003).

Conclusion

Antibiotic prophylaxis reduced wound-related problems after varicose vein surgery. Registration number ISRCTN12467340 (http://www.controlled-trials.com).

Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins

Background

The management of residual varicosities following endovenous laser therapy (EVLT) for varicose veins is contentious. Ambulatory phlebectomy may be performed concomitantly with the initial EVLT, or sequentially as a secondary procedure. This randomized trial compared these two approaches.

Methods

Fifty patients with great saphenous varicose veins were randomized to EVLT alone or EVLT with concomitant ambulatory phlebectomies (EVLTAP). Principal outcomes were procedure duration, pain scores, requirement for secondary procedures and quality of life after 3 months.

Results

EVLTAP took longer, but significantly decreased the requirement for subsequent interventions. There was no impairment in immediate postprocedural pain, Short Form 36 or EuroQol 5D scores with EVLTAP. Median (i.q.r.) Venous Clinical Severity Score (VCSS) at 3 months was lower for EVLTAP than for EVLT alone (0 (0–1) versus 2 (0–2); P &lt; 0·001), with lower Aberdeen Varicose Vein Questionnaire (AVVQ) scores at 6 weeks (7·9 (4·1–10·7) versus 13·5 (10·9–18·1); P &lt; 0·001) and 3 months (2·0 (0·4–7·7) versus 9·6 (2·2–13·8); P = 0·015). At 1 year, there were no differences in VCSS or AVVQ scores.

Conclusion

Concomitant phlebectomy with EVLT prolonged the procedure, but reduced the need for secondary procedures and significantly improved quality of life and the severity of venous disease.

Combined endovenous laser therapy and ambulatory phlebectomy: refinement of a new technique

OBJECTIVE

Sclerotherapy (IS) or ambulatory phlebectomy (AP) are required as subsequent interventions in majority of cases following endovenous laser therapy (EVLT). We assessed whether AP performed concomitantly with EVLT (EVLTAP), is effective, acceptable, and reduces subsequent requirement for interventions.

METHOD

67 patients (70 limbs) with great saphenous varicosities underwent EVLTAP. Pain was assessed on days 1, 4 and 7 using a visual analogue scale (VAS) of 0 to 10. Clinical and ultrasound assessments were done at 1, 6 and 12 weeks (no ultrasound at 6 weeks). Residual varicosities underwent further AP or IS. Patients' satisfaction with the cosmetic outcome and overall treatment was assessed at 12 weeks using a VAS rating.

RESULTS

49 patients (70%) completed follow-up. Median pain scores were 1.6 (IQR 0.2-4.8), 0.3 (0-1.4) and 0.2 (0-1.1) on days 1, 4 and 7 respectively. Ultrasound demonstrated 69 (99%) and 47 (96%) occluded long saphenous veins at 1 and 12 weeks respectively. Subsequent IS or AP was performed on 3 (4%) or 1 (1%) limbs respectively. Cosmetic satisfaction was 9.6 (IQR 8.9-10) and overall satisfaction 9.8 (IQR 9.3-10).

CONCLUSION

EVLTAP produces excellent results, is feasible and acceptable, and obviates need for subsequent procedures in the short-term.

An anti-CD45RO immunotoxin kills HIV-latently infected cells from individuals on HAART with little effect on CD8 memory

CD4+ CD45RO+ T cells are the major latent viral reservoir in HIV-infected individuals and hence a major obstacle in curing the disease. An anti-CD45RO immunotoxin (IT) can decrease the number of both productively and latently infected CD4+ T cells obtained from HIV-infected individuals with detectable viremia. In this study, we determined whether this IT could also kill latently infected replication-competent CD4+ T cells obtained from infected individuals without detectable plasma viremia. Our results demonstrate that ex vivo treatment with the anti-CD45RO IT significantly reduced the frequency of these cells. In contrast, the IT had only a modest effect on the cytomegalovirus-specific memory responses of CD8+ T cells. These results suggest that purging latent cells from infected individuals on highly active antiretroviral therapy with the anti-CD45RO IT might reduce the HIV latent reservoir without seriously compromising CD8+ T cell memory responses.