Determinants of reduced health-related quality of life in pediatric inherited neuropathies

OBJECTIVE

We have shown that health-related quality of life (QOL) in children with inherited neuropathies (Charcot-Marie-Tooth disease [CMT]) is significantly reduced compared to population norms, thus establishing its utility as an outcome measure in therapeutic trials. However, the Australian ascorbic acid trial in children with CMT type 1A (CMT1A) identified no change in QOL scores despite a trend toward improvement in nerve conduction velocities in the treated group. The objective of this study was to identify clinical, electrophysiologic, and functional correlates of QOL in children with CMT1A, to guide future investigations of strategies to improve QOL and reduce disability in these patients.

METHODS

In this cross-sectional study, a series of multivariate regression models were developed to determine whether QOL scores could be explained by demographic and symptom data, standardized measures of gross motor function, foot/ankle and hand/finger involvement, electrophysiology, and gait characteristics in 70 children aged 5-16 years with CMT1A.

RESULTS

Independent determinants of reduced QOL in children with CMT1A, from strongest to weakest, were leg cramps, hand tremor, short step length, reduced long jump distance, ankle inflexibility, poor agility and endurance, advancing age, and foot drop. Many of the standardized clinical and electrophysiologic measures used as endpoints in clinical trials of CMT correlated poorly with QOL.

CONCLUSION

QOL is negatively affected by CMT1A in children. Multivariate modeling suggests that interventions designed to improve leg cramps, tremor, agility, endurance, and ankle flexibility might have a substantial effect on QOL in children with CMT1A.

Dispelling a myth: developing world poverty, inequality, violence and social fragmentation are not good for outcome in schizophrenia

The WHO multi-site studies of schizophrenia concluded the course and outcome of the disorder was better in developing countries. This has become psychiatric lore. However, the reality is that significant political, social and economic ills that characterize many countries in Africa, Latin America and Asia constitute psychosocial stressors that mediate strongly against better outcome in individuals living with this disorder. Outcome studies of schizophrenia in developing countries are reviewed and concepts of poverty, inequality and violence in relation to the course of the illness in this context are debated. The generally poor state of mental health services and policies in these regions are discussed. The belief that community and family life in the developing world is widely intact and that it provides a nurturing environment that facilitates recovery and promotes social and economic empowerment of serious mentally ill individuals is dispelled as a myth. Idealisation of the under-developed South as a haven for schizophrenia sufferers will only add to the already heavy burden experienced by these individuals, their families and these societies in coping with this disabling disease.

Observation of the naive-T-odd Sivers effect in deep-inelastic scattering

Azimuthal single-spin asymmetries of leptoproduced pions and charged kaons were measured on a transversely polarized hydrogen target. Evidence for a naive-T-odd, transverse-momentum-dependent parton distribution function is deduced from nonvanishing Sivers effects for pi(+), pi(0), and K(+/-), as well as in the difference of the pi(+) and pi(-) cross sections.

Randomized trial of custom orthoses and footwear on foot pain and plantar pressure in diabetic peripheral arterial disease

AIM

Custom-made foot orthoses reduce plantar pressure, ulceration and amputation in patients with diabetes mellitus. There is limited evidence of their effect on foot pain. In a randomized, single-blind, sham-controlled trial, the efficacy of custom orthoses on foot pain and plantar pressure in diabetic patients with peripheral arterial disease was investigated.

METHODS

Sixty-one participants were randomly assigned to either custom foot orthoses (n = 30) or sham insoles (n = 31). Both groups also received standardized walking footwear. Outcomes included foot pain and function, mean pressure, toe-brachial index, average daily steps, disability, comfort, quality of life, adherence and adverse events. A multivariate predictive model was constructed to explore factors contributing to pain relief during the trial.

RESULTS

At 8 weeks, 95% of participants provided follow-up data, adherence was high and there were few adverse events. Foot pain and function scores significantly improved at 8 weeks with both custom orthoses and the sham, but there was no significant difference between groups. Custom orthoses reduced pressure significantly more than the sham. There were no significant differences between groups for toe-brachial index, daily steps, disability, comfort or quality of life. Regression modelling identified inappropriate pre-trial footwear as the strongest predictor of foot pain relief during the trial.

CONCLUSIONS

Custom foot orthoses significantly reduced plantar pressure compared with the sham, but there were no significant differences between groups for pain or function. The high-quality walking footwear provided to both groups may explain this finding. Footwear should have greater emphasis as the clinical intervention.

A single-dose, placebo- and moxifloxacin-controlled 3-period study of the effects of temsirolimus on cardiac repolarization in healthy subjects

2551

Background: Temsirolimus (CCI-779) is a novel selective inhibitor of the mammalian target of rapamycin (mTOR) approved by the US FDA for the treatment of patients with advanced renal cell carcinoma. This study was designed to assess the effect of a single dose of 25 mg IV temsirolimus on the corrected QT interval (QTc) in healthy subjects. Methods: Fifty-eight (58) healthy subjects were enrolled in this 3-period crossover study. In periods 1 and 2, subjects were administered IV placebo either alone or with open-label oral moxifloxacin. In period 3, subjects were administered 25 mg IV temsirolimus. Serial ECGs were digitally captured in triplicate and manually over read by a central vendor. The primary statistical objective was to estimate the effect of temsirolimus compared with placebo on change from time-matched baseline QTc at the end of infusion (0.5 hour time point). Secondary endpoints and objectives included estimates of effect at 12 additional time points, population PKPD analyses, and categorical summaries of interval data. Assay sensitivity was evaluated by the effect of moxifloxacin on change from time-matched baseline QTc as compared with placebo. Results: Temsirolimus had no effect on the QTc interval in the primary analysis. At 11 of 12 secondary time points, the upper bound for the temsirolimus QTc 90% CIs for the time-matched change from baseline difference from placebo was less than 10 msec without evidence of QTc trends or relationship to temsirolimus or sirolimus whole blood concentrations. Mean concentrations were comparable to those observed in patients with renal cell carcinoma following administration of 25 mg IV temsirolimus. Moxifloxacin produced a statistically significant increase in the QTc interval as compared with placebo. No relevant PKPD relationship was seen using linear or Emax models. No subject in this study had a QTc interval exceeding 450 msec and no subjects had a change from baseline >30 msec. Conclusions: We conclude that therapeutic exposures of temsirolimus are not associated with changes in QTc interval that reach the level of regulatory significance, according to ICH E14 guidance. The findings are consistent with the lack of QTc interval prolongation observed in studies of cancer patients.

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Social support and intellectual disabilities: a comparison between social networks of adults with intellectual disability and those with physical disability

BACKGROUND

Social support has been identified as a major protective factor in preventing mental health problems and also as a major contributor to quality of life. People with intellectual disabilities (ID) have been identified as having limited social support structures. Interventions have been focused on promoting their social presence and integration. However, previous studies have shown that this does not always lead to the formation of social relationships. To date few studies have looked at how having an ID leads to impoverished social networks. This study aimed to do this by contrasting the social relationships of people with physical disabilities (PD) and people with ID.

METHODS

Two groups of participants were recruited; 30 people with mild ID and 17 people with PD. Social and functional support networks were assessed, in addition to life experiences. Between and within group differences were then explored statistically.

RESULTS

Adults with ID had more restricted social networks than PD, despite being involved in more activities. Social support for adults with ID was mainly provided by family and carers and few relationships with non-disabled people were identified. In contrast adults with PD had larger social networks than had been reported in the mainstream literature and had a balance of relationships with disabled and non-disabled people.

CONCLUSIONS

The results suggest that there are additional processes attached to having an ID, which lead to continued impoverished lifestyles. The findings also endorse other work that suggests being physically integrated and engaged in a wide range of activities does not guarantee good social and emotional support.

Suicide in recently discharged psychiatric patients: a case-control study

BACKGROUND

Few controlled studies have specifically investigated aspects of mental health care in relation to suicide risk among recently discharged psychiatric patients. We aimed to identify risk factors, including variation in healthcare received, for suicide within 3 months of discharge.

METHOD

We conducted a national population-based case-control study of 238 psychiatric patients dying by suicide within 3 months of hospital discharge, matched on date of discharge to 238 living controls.

RESULTS

Forty-three per cent of suicides occurred within a month of discharge, 47% of whom died before their first follow-up appointment. The first week and the first day after discharge were particular high-risk periods. Risk factors for suicide included a history of self-harm, a primary diagnosis of affective disorder, recent last contact with services and expressing clinical symptoms at last contact with staff. Suicide cases were more likely to have initiated their own discharge and to have missed their last appointment with services. Patients who were detained for compulsory treatment at last admission, or who were subject to enhanced levels of aftercare, were less likely to die by suicide.

CONCLUSIONS

The weeks after discharge from psychiatric care represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged. Recent detention under the Mental Health Act and current use of enhanced levels of aftercare may be protective.

Urea metabolism in beef steers fed tall fescue, orchardgrass, or gamagrass hays

Two experiments were conducted to assess effects of endophyte treatments (Exp. 1), forage species (Exp. 2), and supplementation (Exp. 2) on urea production, excretion, and recycling in beef steers. Infusion of (15,15)N-urea and enrichment of urea in urine samples were used to calculate urea-N entry and recycling to the gut. Acceptably stable enrichment of (15)N-urea in urine was obtained after 50 h of intrajugular infusion of (15,15)N-urea, indicating that valid data on urea metabolism can be obtained from steers fed forages twice daily. After adjustment by covariance for differences in N intake among treatments in Exp. 1, steers fed endophyte-infected tall fescue had less (P<0.10) urea-N entry, recycling to the gut, and return of recycled urea-N to the ornithine cycle than those fed endophyte-free or novel endophyte-infected tall fescue. However, urea-N urinary excretion or return to the gut was similar among endophyte treatments when expressed as a proportion of urea-N entry. Urea-N entry and return to the gut in Exp. 2 was similar in steers fed gamagrass or orchardgrass hay after adjustment by covariance for differences in N intake. Less (P<0.01) urinary excretion, expressed as grams per day or as a proportion of urea-N entry, with gamagrass than with orchardgrass was associated with faster in vitro NDF-N digestion with gamagrass. Supplementation of gamagrass or orchardgrass with 1.76 kg/d of readily fermentable fiber and starch decreased urea entry (P<0.06) and urinary excretion of urea (P<0.01). Interactions between hay source and supplement reflected a greater response to supplementation for steers fed orchardgrass than for those fed gamagrass. After adjustment for differences among treatments in N supply, results of both experiments support the concept of improved N use in response to increased carbohydrate fermentability in the rumen, due either to inherent differences in forage fiber or to supplementation with readily fermentable carbohydrate (starch or fiber). Closer coordination of ruminal fermentation of carbohydrate and N sources provided greater and more efficient capture of dietary N as tissue protein in forage-fed steers.

Differential effects of ketoconazole on exposure to temsirolimus following intravenous infusion of temsirolimus

Intravenous (i.v.) temsirolimus, a novel inhibitor of mammalian target of rapamycin, is approved for the treatment of advanced renal cell carcinoma and is being studied in patients with mantle cell lymphoma. Because temsirolimus and its primary metabolite, sirolimus, are metabolised by the cytochrome P450 3A4 pathway (CYP3A4), the potential exists for pharmacokinetic (PK) drug interactions with the numerous agents that modulate CYP3A4 isozyme activity. We investigated the effects of ketoconazole, a potent CYP3A4 inhibitor, on the PK profile of i.v. temsirolimus in healthy adults. Coadministration of 400 mg oral ketoconazole with 5 mg i.v. temsirolimus had no significant effect on temsirolimus maximum concentration (C_max) or area under the concentration curve (AUC). However, mean AUC increased 3.1-fold and AUC_sum (sum of temsirolimus plus sirolimus AUCs) increased 2.3-fold compared with temsirolimus alone. A single 5-mg dose of temsirolimus with ketoconazole was well tolerated, and there were no unexpected safety results. Therefore, in cancer patients receiving 25 mg i.v. temsirolimus, concomitant treatment with agents that have strong CYP3A4 inhibition potential should be avoided. If a concomitant strong CYP3A4 inhibitor is necessary, a temsirolimus dose reduction to 12.5 mg weekly should be considered.

Interventions for the prevention and treatment of pes cavus

BACKGROUND

People with pes cavus frequently suffer foot pain, which can lead to significant disability. Despite anecdotal reports, rigorous scientific investigation of this condition and how best to manage it is lacking.

OBJECTIVES

To assess the effects of interventions for the prevention and treatment of pes cavus.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (April 2007), MEDLINE (January 1966 to April 2007), EMBASE (January 1980 to April 2007), CINAHL (January 1982 to April 2007), AMED (January 1985 to April 2007), all EBM Reviews (January 1991 to April 2007), SPORTdiscuss (January 1830 to April 2007) and reference lists of articles. We also contacted known experts in the field to identify additional published or unpublished data.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials of interventions for the treatment of pes cavus. We also included trials aimed at preventing or correcting the cavus foot deformity.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, assessed trial quality and extracted data.

MAIN RESULTS

Only one trial (custom-made foot orthoses) fully met the inclusion criteria. Two additional cross-over trials (off-the-shelf foot orthoses and footwear) were also included. Both studies assessed secondary biomechanical outcomes less than three-months after randomisation. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The one trial that fully met the inclusion criteria investigated the treatment of cavus foot pain in 154 adults over a three month period. The trial showed a significant reduction in the level of foot pain, measured using the validated 100-point Foot Health Status Questionnaire, with custom-made foot orthoses versus sham orthoses (WMD 10.90; 95% CI 3.21 to 18.59). Furthermore, a significant improvement in foot function measured with the same questionnaire was reported with custom-made foot orthoses (WMD 11.00; 95% CI 3.35 to 18.65). There was also an increase in physical functioning of the Medical Outcomes Short Form - 36 (WMD 9.50; 95% CI 4.07 to 14.93). There was no difference in reported adverse events following the allocation of custom-made (9%) or sham foot orthoses (15%) (RR 0.61; 95% CI 0.26 to 1.48).

AUTHORS' CONCLUSIONS

In one randomised controlled trial, custom-made foot orthoses were significantly more beneficial than sham orthoses for treating chronic musculoskeletal foot pain associated with pes cavus in a variety of clinical populations. There is no evidence for any other type of intervention for the treatment or prevention of foot pain in people with a cavus foot type.

Community nurses and self-management of blood glucose

Self-monitoring of blood glucose (SMBG) is commonly recommended to patients with diabetes, although the rationale for this is unclear. This small research project was designed to explore the reasons why nurses working in the community recommend SMBG. Seven interviews were carried out with community nurses caring primarily for housebound patients. Those interviewed believed that a sound evidence-base supported the recommendation that patients test their blood, but not urine, for glucose levels. Though nurses believed in the importance of patient choice and empowerment, the scope for these was limited among housebound patients. There was no evidence that patients understood how to respond to test results, or that comprehensive care planning was normal practice. Although small, this study suggests that nurses working in community settings may need to update their knowledge. It also suggests that a national debate is necessary to disseminate better the evidence about SMBG, and its implications for nursing practice.

Does stretching increase ankle dorsiflexion range of motion? A systematic review

BACKGROUND

Many lower limb disorders are related to calf muscle tightness and reduced dorsiflexion of the ankle. To treat such disorders, stretches of the calf muscles are commonly prescribed to increase available dorsiflexion of the ankle joint.

HYPOTHESIS

To determine the effect of static calf muscle stretching on ankle joint dorsiflexion range of motion.

STUDY DESIGN

A systematic review with meta-analyses.

METHODS

A systematic review of randomised trials examining static calf muscle stretches compared with no stretching. Trials were identified by searching Cinahl, Embase, Medline, SportDiscus, and Central and by recursive checking of bibliographies. Data were extracted from trial publications, and meta-analyses performed that calculated a weighted mean difference (WMD) for the continuous outcome of ankle dorsiflexion. Sensitivity analyses excluded poorer quality trials. Statistical heterogeneity was assessed using the quantity I2.

RESULTS

Five trials met inclusion criteria and reported sufficient data on ankle dorsiflexion to be included in the meta-analyses. The meta-analyses showed that calf muscle stretching increases ankle dorsiflexion after stretching for < or = 15 minutes (WMD 2.07 degrees; 95% confidence interval 0.86 to 3.27), > 15-30 minutes (WMD 3.03 degrees; 95% confidence interval 0.31 to 5.75), and > 30 minutes (WMD 2.49 degrees; 95% confidence interval 0.16 to 4.82). There was a very low to moderate statistical heterogeneity between trials. The meta-analysis results for < or = 15 minutes and > 15-30 minutes of stretching were considered robust when compared with sensitivity analyses that excluded lower quality trials.

CONCLUSIONS

Calf muscle stretching provides a small and statistically significant increase in ankle dorsiflexion. However, it is unclear whether the change is clinically important.