Effect of a paraprofessional home-visiting intervention on American Indian teen mothers’ and infants’ behavioral risks: a randomized controlled trial

OBJECTIVE

The authors sought to examine the effectiveness of Family Spirit, a paraprofessional-delivered, home-visiting pregnancy and early childhood intervention,in improving American Indian teen mothers’ parenting outcomes and mothers’and children’s emotional and behavioral functioning 12 months postpartum.

METHOD

Pregnant American Indian teens(N=322) from four southwestern tribal reservation communities were randomlyassigned in equal numbers to the Family Spirit intervention plus optimized standard care or to optimized standard care alone. Parent and child emotional and behavioral outcome data were collected at baseline and at 2, 6, and 12 months postpartum using self-reports, interviews,and observational measures.

RESULTS

At 12 months postpartum, mothers in the intervention group had significantly greater parenting knowledge parenting self-efficacy, and home safety attitudes and fewer externalizing behaviors,and their children had fewer externalizing problems. In a subsample of mothers with any lifetime substance use at baseline (N=285; 88.5%), children in the intervention group had fewer externalizing and dysregulation problems than those in the standard care group, and fewer scored in the clinically “at risk” range ($10th percentile) for externalizing and internalizing problems. No between-group differences were observed for outcomes measured by the Home Observation for Measurement of the Environment scale.

CONCLUSIONS

Outcomes 12 months postpartum suggest that the Family Spirit intervention improves parenting and infant outcomes that predict lower lifetime behavioral and drug use risk for participating teen mothers and children.

Morphological changes of the lateral meniscus in end-stage lateral compartment osteoarthritis of the knee

OBJECTIVE

The aim of this study was to evaluate the morphological changes of the lateral meniscus in end-stage lateral compartment osteoarthritis (OA) of the knee.

METHODS

One hundred fifty-eight knee joints from 133 patients that subsequently underwent total knee joint arthroplasty from January 2008 to December 2009 were enrolled. There were 26 men and 107 women. Their ages ranged from 56 to 81 (mean 67.4 ± 6.5 years). All study participants had complete obliteration of the lateral joint space identified by weight-bearing radiography. Meniscal position was assessed by measuring meniscal subluxation and meniscal height. The meniscal morphology was assessed using a modification of the whole-organ magnetic resonance imaging score (WORMS). The frequency of different meniscal morphology and their respective positions was calculated.

RESULTS

The predominant type (42.4%, 53.8% and 52.5% in the anterior horn, mid-body and posterior horn, respectively) of abnormal meniscal morphology was a complete maceration/destruction or complete resection. The anterior horn of non-macerated lateral meniscus was more subluxed than that of the non-macerated medial meniscus in patients with lateral OA.

CONCLUSION

This study suggests that the lateral meniscus in persons with end-stage lateral OA are mostly macerated or destroyed. Also, unlike isolated end-staged medial compartment OA, the anterior horn of the lateral meniscus in isolated end-stage lateral OA is commonly affected.

Quantifying the Erlenmeyer flask deformity

OBJECTIVE

Erlenmeyer flask deformity is a common radiological finding in patients with Gaucher's disease; however, no definition of this deformity exists and the reported prevalence of the deformity varies widely. To devise an easily applied definition of this deformity, we investigated a cohort of knee radiographs in which there was consensus between three experienced radiologists as to the presence or absence of Erlenmeyer flask morphology.

METHODS

Using the presence or absence of Erlenmeyer flask morphology as a benchmark, we measured the diameter of the femur at the level of the physeal scar and serially at defined intervals along the metadiaphysis.

RESULTS

A measured ratio in excess of 0.57 between the diameter of the femoral shaft 4 cm from the physis to the diameter of the physeal baseline itself on a frontal radiograph of the knee predicted the Erlenmeyer flask deformity with 95.6% sensitivity and 100% specificity in our series of 43 independently diagnosed adults with Gaucher's disease. Application of this method to the distal femur detected the Erlenmeyer flask deformity reproducibly and was simple to carry out.

CONCLUSION

Unlike diagnostic assignments based on subjective review, our simple procedure for identifying the modelling deformity is based on robust quantitative measurement: it should facilitate comparative studies between different groups of patients, and may allow more rigorous exploration of the pathogenesis of the complex osseous manifestations of Gaucher's disease to be undertaken.

Clinical relevance of thiopurine S-methyltransferase gene polymorphisms

The therapeutic response to thiopurines may result in either severe toxic or inadequate effect based on the interindividual genetic variability. Same drug doses of various anticancer drugs cause considerable interindividual differences in the therapeutic response. Genetic factors have a major impact on effectiveness of several anticancer drugs such as mercaptopurine, 5-fluorouracil, platinum agents, and cyclophosphamide. Heredity related differences in interindividual response to thiopurine therapy represent perhaps the most compelling evidence of pharmacogenomics' usefulness in identification of patients in risk for adverse drug reactions. A number of variations in the gene for thiopurine methyltransferase (TPMT) have been associated with the low activity of this enzyme. Patients with intermediate and low activity of TPMT have a greater incidence of thiopurine toxicity. This minireview summarizes results of studies assessing the role of genetic polymorphisms in the gene encoding TPMT and their relationship to the toxicity of thiopurines.

Feasibility and impact of a structured, exercise-based rehabilitation programme for intensive care survivors

Our objective was to assess the impact of an outpatient physiotherapy-led rehabilitation programme on exercise capacity and anxiety and depression scores in a cohort of adult intensive care survivors. In a prospective study in a teaching hospital, 38 general intensive care survivors following hospital discharge underwent an established physiotherapy-led outpatient rehabilitation programme. The programme involved 2 hours of supervised exercise and education sessions each week and two unsupervised exercise sessions each week for 6 weeks. Assessments took place 1 week before and 1 week after completing the programme. Primary outcome measures were changes in exercise capacity measured using the 6-minute walk test (6MWT) and incremental shuttle walk test (ISWT). Secondary outcome measures were changes in anxiety and depression scores using the Hospital Anxiety and Depression Scale (HADS). Median distance covered in the 6MWT improved by 160 metres (p<0.001), and median distance covered in the ISWT also improved by 160 metres (p < 0.001). Significant improvement in anxiety (p = 0.001) and depression (p = 0.001) scores were also seen. Outpatient, physiotherapy-lead rehabilitation appears to improve both exercise capacity and anxiety and depression scores in a cohort of intensive care survivors. A similar programme should be tested in a randomised controlled trial.

Normal chest radiography in pulmonary tuberculosis: implications for obtaining respiratory specimen cultures

SETTING

Urban tuberculosis (TB) clinic, Nashville, Tennessee, USA.

OBJECTIVE

Chest radiographs (CXRs) help in the diagnosis of pulmonary TB, but may be normal. Mycobacterium tuberculosis in culture is diagnostic of TB, but cultures are not routinely obtained in resource-poor settings. We examined rates and risk factors for pulmonary TB associated with normal CXR.

DESIGN

An observational cohort study was performed among all respiratory culture-positive TB cases referred to the Nashville Health Department from October 1992 to July 2003. Clinical factors, demographics and underlying medical conditions were assessed.

RESULTS

Of 601 study patients, 53 (9%) had normal CXRs: 31/138 (22%) were human immunodeficiency virus (HIV) infected and 22/463 (5%) were non-HIV-infected/unknown (P<0.001). Among HIV-infected patients, normal CXR was more likely in persons with renal failure (13% vs. 3%, P=0.048). Among non-HIV-infected/unknown patients, normal CXR was more likely in those who were asymptomatic at presentation (32% vs. 13%, P=0.022). In multivariable logistic regression analysis, HIV infection was associated with an increased risk of normal CXR (odds ratio [OR] 6.61, P<0.0001); factors associated with reduced risk were dyspnea (OR 0.24, P=0.026), positive sputum smear (OR 0.45, P=0.028) and cough (OR 0.48, P=0.038).

CONCLUSIONS

The rate of normal CXR among persons with culture-confirmed pulmonary TB was high. Respiratory specimen cultures should be obtained in TB suspects with a normal CXR, particularly HIV-infected persons.

Intimal Neovascularisation is a Prominent Feature of Atherosclerotic Plaques in Diabetic Patients with Critical Limb Ischaemia

INTRODUCTION

Neovascularisation of atherosclerotic plaques correlates with increased plaque instability and subsequent risk of vascular complications. Diabetics have widespread atherosclerotic involvement of the arterial tree and a more aggressive form of the disease culminating in increased plaque instability. This results in a greater incidence of ischaemic sequelae than in non-diabetics. Previous studies have examined neovascularisation as a marker of plaque instability in both the carotid and coronary territories and revealed a greater degree in both symptomatic and diabetic patients. This is the first study to examine intimal neovascularisation in lower limb peripheral arterial disease.

METHODS

Arterial specimens were taken from 20 patients, ten of whom were type 2 diabetics, undergoing major lower limb amputation for unreconstructable critical ischaemia. Sections were stained with H&E for morphological assessment and inflammatory cell characterisation. Additional sections underwent immunohistochemical staining for CD31 and von-Willebrand Factor (vWF) and the number of intimal vessels per four 40x magnification fields assessed.

RESULTS

There was a more prominent inflammatory infiltrate in diabetic subjects compared to non-diabetic controls. Diabetic patients had a greater degree of intimal neovascularisation compared to controls with a median of 11.5 and 2.0 vessels per field respectively (P<0.05). Sub-group analysis revealed that diabetic patients medicating with HMG-CoA Reductase inhibitors (Statins) had a greater degree of neovascularisation compared to those not taking this class of medication.

CONCLUSION

Diabetic patients with critical limb ischaemia requiring amputation demonstrate a greater degree of plaque intimal neovascularisation and inflammatory infiltrate compared to their non-diabetic counterparts. This may explain the greater plaque instability and subsequent cardiovascular complications seen in these patients.

Genetic tests for predicting the toxicity and efficacy of anticancer chemotherapy

The standard anticancer therapy based "on one size fits all" modality has been determined to be ineffective or to be the cause of adverse drug reactions in many oncologic patients. Most pharmacogenetic and pharmacogenomic studies so far have been focused on toxicity of anticancer drugs such as 6-mercaptopurine, thioguanine, irinotecan, methotrexate, 5-fluorouracil (5-FU). Variation in genes are known to influence not only toxicity, but also efficacy of chemotherapeutics such as platinum analogues, 5-FU and irinotecan. The majority of current pharmacogenetic studies focus on single enzyme deficiencies as predictors of drug effects; however effects of most anticancer drugs are determined by the interplay of several gene products. These effects are polygenic in nature. This review briefly describes genetic variations that may impact efficacy and toxicity of drugs used in cancer chemotherapy.