A randomized placebo-controlled trial of nicotinamide riboside in older adults with mild cognitive impairment

Nicotinamide riboside (NR) increases blood levels of NAD+, a cofactor central to energy metabolism, and improves brain function in some rodent models of neurodegeneration. We conducted a placebo-controlled randomized pilot study with the primary objective of determining safety of NR in older adults with mild cognitive impairment (MCI). Twenty subjects with MCI were randomized to receive placebo or NR using dose escalation to achieve, and maintain, a final dose of 1 g/day over a 10-week study duration. The primary outcome was post-treatment change from baseline measures of cognition (Montreal Cognitive Assessment, MoCA). Predefined secondary outcomes included post-treatment changes in cerebral blood flow (CBF); blood NAD+ levels; and additional neurocognitive, psychometric, and physical performance tests. DNA methylation was assessed in peripheral blood mononuclear cells (PBMCs) as an exploratory outcome. The target NR dose was safely achieved as evidenced by a 2.6-fold increase in blood NAD+ in the NR group (p < 0.001, 95% CI [17.77, 43.49]) with no between-group difference in adverse event reporting. MoCA and other neurocognitive and psychometric metrics remained stable throughout the study. NR reduced CBF in the default mode network (DMN) with greatest differences observed in the left inferior parietal lobe (IPL) (DMN p = 0.013, μ = 0.92, 95% CI [0.23, 1.62]; left IPL p = 0.009, μ = 1.66, 95% CI [0.5, 2.82]). Walking speed in the placebo group significantly improved across the study duration suggestive of a practice effect but did not change in the NR group (p = 0.0402 and p = 0.4698, respectively). Other secondary outcome measures remained stable. Global methylation analyses indicated a modest NR-associated increase in DNA methylation and concomitant reduction in epigenetic age as measured by PhenoAge and GrimAge epigenetic clock analyses. In summary, NR significantly increased blood NAD+ concentrations in older adults with MCI. NR was well tolerated and did not alter cognition. While CBF was reduced by NR treatment, statistical significance would not have withstood multiple comparisons correction. A larger trial of longer duration is needed to determine the potential of NR as a strategy to improve cognition and alter CBF in older adults with MCI. ClinicalTrials.gov NCT02942888.

CLINICAL TRIAL OF METFORMIN FOR FRAILTY PREVENTION IN COMMUNITY-DWELLING OLDER ADULTS WITH PRE-DIABETES

Background

Metformin may reduce frailty through improving insulin resistance and inflammation, aging mechanisms known to increase frailty risk. We describe a randomized clinical trial of metformin for frailty prevention in community-dwelling older adults with pre-diabetes and provide baseline characteristics of randomized participants.

Methods

Older adults (65+ years) are studied in this randomized, double-blind, placebo-controlled trial of metformin (max 2,000 mg/day). Pre-diabetes, required for inclusion, is assessed by 2-hour oral glucose tolerance test (OGTT). Individuals with glomerular filtration rate < 45 mL/min and frail individuals (Fried criteria) are excluded. The primary outcome, frailty, is assessed by both Fried criteria and frailty index. Secondary outcomes are physical function (short physical performance battery), lower extremity strength (Biodex), 6-minute walk, inflammation (systemic and skeletal muscle tissue), muscle insulin signaling, insulin sensitivity (insulin clamp), glucose tolerance (OGTT), and body composition (dual-energy x-ray absorptiometry). Subjects are followed for 2 years with safety assessments every 3 months and frailty assessment and OGTT every 6 months.

Results

145 participants (49% female, 35% Hispanic) are randomized. Mean age is 71.8 ± 5.4 years (range: 65-88), body mass index is 30.8 ±6 kg/m2, and Hemoglobin A1c is 5.6 ±0.4%. Using Fried criteria, 63.4% have frailty score of 0, 30.3% a score of 1, and 6.2% a score of 2.

Conclusion

Metformin is being examined as a potential therapeutic agent to prevent frailty in older adults with pre-diabetes. Findings from this trial may have future implications for screening and treatment of pre-diabetes in older adults for the prevention of frailty.

A Randomized Placebo-Controlled Trial of Metformin for Frailty Prevention in Older Adults

Frailty is a progressive physical decline leading to higher morbidity and mortality in older adults. Previous studies have demonstrated shared mechanisms between insulin resistance, inflammation, and frailty. The purpose of this trial is to determine whether metformin prevents frailty in non-frail, community-dwelling older adults (≥65 years) with pre-diabetes, determined by 2-hour oral glucose tolerance test (OGTT). Frail individuals (Fried criteria) and those with renal impairment (glomerular filtration rate &lt;45 mL/min) are excluded. Eligible participants are randomized to metformin or placebo and followed for two years. The primary outcome is frailty; secondary outcomes include physical function (short physical performance battery), systemic and skeletal muscle inflammation (plasma and muscle inflammatory markers), muscle insulin signaling (muscle biopsy), insulin sensitivity (insulin clamp), glucose tolerance (OGTT), and body composition (dual-energy x-ray absorptiometry) measurements. Participants are followed every 3 months for safety assessments, every 6 months for frailty assessment and OGTT, and every 12 months for muscle biopsy. Currently, 99 participants, including 53 (53.5%) male and 91 (91.9%) white, are active (54) or have completed the study (35). At baseline, mean age was 72.3 ± 5.5 years, body mass index was 30.7 ± 5.9 kg/m2, and Hemoglobin A1c was 5.73 ± 0.37%. Mean frailty score was 0.5 ± 0.6 and the proportion of non-frail and pre-frail participants were 58.6% (n = 58) and 41.5% (n = 41), respectively. Findings of this clinical trial may have future implications for the use of metformin in older adults with pre-diabetes in order to prevent the onset of frailty.

A geriatrics walking clinic improves hemoglobin A1c and timed gait in older veterans with type 2 diabetes

Over one quarter of older adults in the U.S. has diabetes; and, physical activity is important for the promotion of healthy aging in this population. The purpose of this clinical demonstration project is to evaluate the effect of physical activity in the form of walking on glycemic control and timed gait in older Veterans with type 2 diabetes (T2D). Veterans aged ≥60 years were enrolled in the Geriatrics Walking Clinic (GWC), a clinical demonstration project, at South Texas Veterans Health Care System. GWC is a 6-week clinical program that promotes physical activity and is delivered by a registered nurse/diabetes educator and geriatrician. Veterans were recruited from the VA clinics. Enrolled patients received a pedometer at an initial face-to-face visit, were followed with weekly phone calls to monitor steps/day, received encouragement, and participated in a final face-to-face visit at the end of 6 weeks. In a sub-set of patients with T2D, we performed a chart review and recorded Hemoglobin A1c (HbA1c) at 3, 6, and 12 months after completion of the program. Timed Gait, a major characteristic of frailty, was measured at baseline and after completing the program. Change in HbA1c and timed gait compared to baseline was examined using paired t-tests. Sixty-two patients had HbA1c values available and were included in this analysis. Of these, 36, 52, and 61 patients had repeat HbA1c at 3, 6, and 12 months after the intervention, respectively. Mean age was 68 ± 6 years, 58% were Hispanic, and 92% males. HbA1c improved at 3 months (-0.49, 95% CI: -0.87 to -0.12, p=0.013), at 6 months (-0.40, 95% CI: -0.68 to -0.12, p=0.006), and at 12 months (-0.30, 95% CI: -0.57 to -0.029, p=0.031) compared to baseline. Timed Gait also improved (9.3 ±1.7 vs. 10.2 ±1.8, p<0.001). The finding highlights that older patients with T2D benefit from a GWC with improved glycemic control and timed gait.

Telehealth Competencies for Interprofessional Teams Caring for Older Adults and Care Partners

Providing interprofessional geriatric care via telehealth is a unique clinical skillset that differs from providing face-to-face care. The lack of clear guidance on telehealth best practices for providing care to older adults and their care partners has created a systems-based practice educational gap. For several years, GRECC Connect has provided interprofessional telehealth visits to older adults, frequently training interprofessional learners in the process. Using our interprofessional telehealth expertise, the GRECC Connect Education Workgroup created telehealth competencies for the delivery of care to older adults and care partners for interprofessional learners. Competencies incorporate key telehealth, interprofessional and geriatric domains, and were informed by diverse stakeholders within the Veterans Health Administration. During this symposium, comments will be solicited from attendees. Once finalized, these competencies will drive the development of robust curricula and evaluation measures aimed at training the next generation of interprofessional providers to expertly care for older adults via telehealth.

National Geriatric Network Rapidly Addresses Trainee Telehealth Needs in Response to COVID-19

BACKGROUND/OBJECTIVES

Coronavirus disease 2019 (COVID‐19) has pushed many geriatric healthcare providers to attempt video visits for the first time. Although the Veterans Health Administration (VA) is a pioneer in telemedicine, rapid shifts to nearly exclusive use of telehealth for healthcare delivery and changes regarding trainee engagement in telehealth served as the impetus for rapidly assessing telehealth training needs.

DESIGN

National needs assessment (online survey) of associated health trainees and medical fellows affiliated with Geriatric Research Education and Clinical Centers (GRECCs).

SETTING

National GRECC network ‐‐ 20 VA centers of excellence focused on supporting Veterans as they age. Each GRECC is affiliated with a school of medicine at a major university.

PARTICIPANTS

Trainees (n = 89) representing 12 disciplines.

RESULTS

Two‐thirds of participants had received some telehealth training. However, most had never done a video‐to‐home visit, and, regardless of telehealth experience, they reported low confidence. Based on open‐ended questions exploring training needs, educational resources were rapidly developed and disseminated.

INTERVENTION

Within 1 week of the assessment, a nuts‐and‐bolts guide regarding remote access, technology requirements, video‐conferencing platforms, and managing emergencies was sent to the national network of GRECC associate directors for education for dissemination among discipline‐specific training directors at their sites. This resource was subsequently submitted to the national VA COVID Strong Practices SharePoint site. An interdisciplinary team of geriatric specialists with extensive video‐to‐home experience also organized a national webinar that peaked at just over 700 participants. GRECC Connect, a network of geriatric specialty teams funded to improve care access for rural older veterans using telehealth and associated health training programs at each GRECC facilitated rapid development and dissemination of both resources.

CONCLUSION

We quickly identified and responded to telehealth training needs of geriatrics trainees to optimize care for rural older adults as part of a rapid response to COVID‐19. Although the webinar and nuts‐and‐bolts resources were developed within the VA context, they have demonstrated high demand and broader applicability. Results should continue to inform curriculum development efforts to address telehealth training gaps within and outside the VA.

Rationale and Study Design of a Randomized Clinical Trial of Metformin to Prevent Frailty in Older Adults With Prediabetes

BACKGROUND

Frailty is a geriatric syndrome that leads to poor health outcomes with aging. Previous studies have demonstrated that insulin resistance and inflammation predict frailty onset. Metformin is a widely used, well-tolerated drug that improves insulin sensitivity and displays anti-inflammatory properties. It is also known to prevent diabetes onset in adults with prediabetes. We hypothesize that metformin in older adults with prediabetes will promote healthy aging and prevent frailty. Here we describe an ongoing placebo-controlled, double-blinded clinical trial of metformin for the prevention of frailty in older adults with prediabetes.

METHODS

Older adults aged more than 65 years are randomized to metformin or placebo and are followed for 2 years. Prediabetes, required for inclusion, is assessed by 2-hour oral glucose tolerance test. Exclusion criteria are baseline frailty (Fried criteria), diabetes, dementia, untreated depression, active malignancy, or severe cardiovascular, pulmonary, and neurologic diseases. Primary outcome is frailty; secondary outcomes are physical function (Short Physical Performance Battery), systemic and skeletal muscle tissue inflammation, muscle insulin signaling, insulin sensitivity (insulin clamp), glucose tolerance (oral glucose tolerance test), and body composition (dual-energy x-ray absorptiometry). Subjects are followed every 3 months for safety assessments and every 6 months for frailty assessment (Fried criteria) and oral glucose tolerance test, and every 12 or 24 months for secondary outcomes. Enrollment of 120 subjects (completers) will take place over a 2-year period.

CONCLUSION

Metformin is being examined in this study as a potential therapeutic agent to prevent frailty in older adults with prediabetes. Findings from this trial may have future implications for the screening and potential treatment of prediabetes in older patients with metformin for the prevention of frailty.

THE SAGE SYMPOSIUM: A MODEL FOR HANDS-ON INTERACTIVE CONTINUING EDUCATION

Current graduate and postgraduate medical education has minimal geriatric and palliative care curricular requirements, leaving Continuing Education (CE) programs poised to fill a critical educational niche. The San Antonio Geriatric and Palliative Education (SAGE) Symposium was a 3 day long interprofessional CE conference for providers caring for older adults. SAGE addressed geriatric knowledge, skill, and attitude deficits in practicing providers by incorporating: 1) a community and provider based needs assessment, 2) active skills sessions culminating in a health fair, and 3) multimedia based reflective exercises. Needs Assessment (Knowledge): A video needs assessments of older adults were performed using a convenience sampling methodology in 13 non-healthcare public locations in each quadrant of the city. 23 respondents were interviewed before reaching thematic saturation with 3 main themes: geriatric syndromes, patient-provider relationships, and support. Content areas for the course were derived from the needs assessment. Skills Sessions (Skills): In addition to standard plenary sessions, multiple active breakout session taught attendees common geriatric skills. On the last day of the conference, attendees applied these skills under supervision at a senior community health fair. Reflective Exercises (Attitudes): Videos, poems, and artwork with themes on aging were displayed during conference breaks. Attendees received CE credit for electronically submitting short reflections to each multimedia piece. Reflections were compiled and reported back to the group at the end of the conference. By changing the traditional CE conference format to an interactive experience, the SAGE Symposium was able to address knowledge, skills, and attitudes towards aging in its attendees.

IMPROVING GERIATRIC CARE OF INTERPROFESSIONAL PRACTICING PROVIDERS

Practicing providers often struggle with the care of older adults due to knowledge, skill, and attitude barriers. In an attempt to improve employee engagement in the care of older adults, the Geri-EMPOWER (Empowering Medical Providers and Older adults With strategies to Escape Readmission) program was initiated. In this program, case managers and visiting VA rural geriatric scholars participated in a two days of intensive educational sessions including lectures, shadowing inpatient teams and clinic providers, a dementia simulation learning exercise, and an Observed Structured Clinical Exam (OSCE) with standardized patient encounters. The 15 initial participating trainees came from a variety of medical backgrounds including physicians, nurse practitioners, nurses, social workers, and psychologists. A 10 item knowledge based pretest and posttest was constructed using the learning objectives of the course. Skills of attendees were directly observed during 4 OSCE stations. Attitudes towards older adults were measured before and after the intervention using the Caroline Opinions on Care of Older Adults (COCOA) scale. Geriatric and palliative care knowledge improved with average knowledge test scores improving from 63% to 86% before and after the course. Participants obtained all minimum competencies during their OSCE exam, and rated this session very highly in their course feedback. Attitudes towards older adults were also found to improve with an average COCOA score increase of 9 points before and after the educational sessions. This innovative course based in adult-learning theory demonstrates that employed interprofessional providers can quickly improve knowledge, skills, and attitudes towards older adults.

An Individualized Low-Intensity Walking Clinic Leads to Improvement in Frailty Characteristics in Older Veterans

BACKGROUND

Sedentary lifestyle leads to worse health outcomes with aging, including frailty. Older adults can benefit from regular physical activity, but exercise promotion in the clinical setting is challenging.

OBJECTIVES

The objective of this clinical demonstration project was to implement a Geriatric Walking Clinic for older adults and determine whether this clinical program can lead to improvements in characteristics of frailty.

DESIGN

This was a clinical demonstration project/quality improvement project.

SETTING

Outpatient geriatrics clinic at the South Texas Veterans Health Care System (STVHCS).

PARTICIPANTS

Older Veterans, aged ≥60 years.

INTERVENTION

A 6-week structured walking program, delivered by a registered nurse and geriatrician. Patients received a pedometer and a comprehensive safety evaluation at an initial face-to-face visit. They were subsequently followed with weekly phone calls and participated in a final face-to-face follow-up visit at 6 weeks.

MEASUREMENTS

Grip strength (handheld dynamometer), gait speed (10-ft walk), Timed Up and Go (TUG), and body mass index (BMI) were assessed at baseline and follow-up. Frailty status for gait speed was assessed using Fried criteria.

RESULTS

One hundred eighty five patients completed the program (mean age: 68.4 ±7 years, 88% male). Improvements from baseline to follow-up were observed in average steps/day, gait speed, TUG, and BMI. Improvement in gait speed (1.13 ±0.20 vs. 1.24 ± 0.23 meter/second, p<0.0001) resulted in reduced odds of meeting frailty criteria for slow gait at follow-up compared to the baseline examination (odds ratio = 0.31, 95% confidence interval: 0.13-0.72, p = 0.01).

CONCLUSIONS

Our findings demonstrate that a short duration, low-intensity walking intervention improves gait speed and TUG. This new clinical model may be useful for the promotion of physical activity, and for the prevention or amelioration of frailty characteristics in older adults.

Induction of labour with retrievable prostaglandin vaginal inserts: outcomes following retrieval due to an intrapartum adverse event

OBJECTIVE

To assess adverse event (AE) resolution, delivery mode and neonatal outcomes after misoprostol or dinoprostone vaginal insert (MVI or DVI) retrieval due to AE during induction of labour (IOL).

DESIGN

Randomised, double-blind trial, EXPEDITE.

SETTING

Thirty five obstetric departments, USA.

POPULATION

Consisted of 1358 pregnant women with modified Bishop score ≤4 eligible for pharmacological IOL.

METHODS

Post hoc analysis.

MAIN OUTCOME MEASURES

AEs prompting insert retrieval, times to AE resolution, delivery, delivery mode and neonatal intensive care unit (NICU) admissions.

RESULTS

77/678 (11.4%) and 27/680 (4.0%) women had MVI and DVI retrieved due to AE, respectively (P < 0.001). The most common AEs prompting retrieval were uterine tachysystole with fetal heart rate (FHR) involvement and category II/III FHR pattern. Time to AE resolution varied for both treatments depending on the type of AE. For uterine tachysystole with FHR involvement, median resolution times were 1 hour 34.5 minutes (n = 36) and 8.5 minutes (n = 8) for MVI and DVI, respectively. Caesarean delivery occurred in a high proportion of women with insert retrieved due to AE (MVI: 44/77 (57.1%); DVI: 19/27 (70.4%)); the majority of caesareans were performed at least several hours after insert retrieval. Median times from retrieval to any delivery were not increased for women with insert retrieved due to AE. NICU admissions were 8/77 (10.4%) and 1/27 (3.7%) for MVI and DVI, respectively (P = 0.440).

CONCLUSIONS

AEs leading to insert retrieval were primarily uterine tachysystole with FHR involvement and category II/III FHR patterns. Insert retrieval due to an AE did not prolong time to delivery for either prostaglandin insert.

TWEETABLE ABSTRACT

Induction with prostaglandin vaginal inserts: outcomes following retrieval due to intrapartum adverse event.

Histologic Characteristics and KIT Staining Patterns of Equine Cutaneous Mast Cell Tumors

Mast cell tumors are uncommon in horses and typically have a benign clinical course, but there are occasional reports of more aggressive behavior. The objective of this study was to review histologic features and KIT expression patterns of 72 previously diagnosed equine cutaneous mast cell tumors to determine if either is associated with clinical outcomes. Biopsy specimens were reviewed using histologic criteria derived from grading schemes, and KIT antibody expression patterns used in canine tumors and surveys were sent to referring veterinarians for follow-up clinical data. Arabians were overrepresented relative to the reference population. Most tumors were well differentiated with low mitotic rates (96%), and aberrant KIT staining patterns, as described in dogs, were uncommonly identified (12%). Associated clinical disease was uncommon and no tumors exhibited malignant behavior. Overall, KIT staining pattern and histologic features were not associated with poor clinical outcome or abnormal tumor behavior.

On discovering relevant scales in surface roughness measurement--an evaluation of a band-pass method

When characterizing surfaces and searching for correlations to functional properties, such as friction, finding the right scale of roughness for evaluation can improve correlations. However, in traditional roughness parameter analysis, a wide range of scales, or all scales of topography in the surface roughness measurements are evaluated together. In this study a multi-scale method using a series of band-pass filters is employed for finding scales of topography with strong correlations to friction.

Treatment of canine haemangiosarcoma with suberoylanilide hydroxamic acid, a histone deacetylase inhibitor

A case report is presented by describing the treatment of a 12-year-old dog - diagnosed with haemangiosarcoma (HSA) - with suberoylanilide hydroxamic acid (SAHA), a histone deacetylase (HDAC) inhibitor. The drug was administered orally, on a daily basis, approximately 2 weeks post-splenectomy at a dose of 3 mg kg(-1). HSA is a lethal malignancy of the endothelium, which is usually disseminated by the time it is diagnosed. Median survival time, usually, is no longer than 80 days. Following treatment with SAHA, no sign of malignant growth could be discerned by means of diagnostic abdominal ultrasound, chest X-ray or with the help of clinical symptoms, over a period of >1000 days. The precise mechanism by which HDAC inhibitors exert their anti-cancer effects is uncertain, but evidence suggests that exposure to SAHA generates hyperacetylated chromosomal histones, which, in turn, facilitates the expression of tumour suppressor genes turned off by epigenetic mechanisms during neoplastic transformation of the endothelium.

Passive, opportunistic wildlife disease surveillance in the Rocky Mountain Region, USA

Wild animals can play an important role in the epidemiology of infectious disease with significant public health, economic and ecological consequences. As it is often challenging to conduct unbiased surveillance in free-ranging mammal populations, passive, opportunistic case identification has been widely used for detection of disease events in wild animals. This study evaluated the role of different agencies and organizations in the Rocky Mountain Region of the USA to identify significant wildlife health events or aggregate information from multiple sources. Overall wildlife rehabilitators were in contact with the greatest number of animals; however, the data from these groups, in its current state, are insufficient for surveillance purposes. Wild animal data from all survey groups aggregated at the level of state wildlife organizations; these agencies are therefore central in this type of surveillance activity and require sufficient resources to ensure that appropriate testing is conducted.

A phase II trial testing the thermal dose parameter CEM43 degrees T90 as a predictor of response in soft tissue sarcomas treated with pre-operative thermoradiotherapy

We prospectively evaluated whether delivering a thermal dose of > 10 cumulative equivalent minutes at 43 degrees C to >90% of the tumour sites monitored (CEM43 degrees T90) would produce a pathologic complete response (pCR) in > 75% of high-grade soft tissue sarcomas treated pre-operatively with thermoradiotherapy. The impact of thermal dose on local failure (LF), distant metastasis (DM), and toxicity was also assessed. Thirty-five patients > or = 18 years old with grade 2 or 3 soft tissue sarcomas accessible for invasive thermometry were enrolled on the protocol. All patients received megavoltage external beam radiotherapy (RT) in daily fractions of 1.8-2.0 Gy, five times a week, to a median total dose of 50 Gy and an initial hyperthermia treatment (HT) of I h duration utilizing the BSD 2000 with Sigma 60 or MAPA applicators at frequencies of 60-140 MHz. Further HT was given for patients with CEM43 degrees T90 > 0.5 after initial HT ('heatable' patients), twice a week to a maximum of 10 HT or CEM43 degrees T90 > 100. Of the 35 patients entered, 30 had heatable tumours, one of which was inevaluable for pCR or LF as the patient died of DM prior to surgery, leaving 29 evaluable patients. Of these 29 patients, 15 (52%) had a pCR (95% CI: 37-73%), significantly less than the projected rate of > or = 75% (p = 0.02). Of the 25 heatable tumours that achieved CEM43 degrees T90 > or = 10, 14 (56%) had a pCR (95% CI: 39-78%) significantly less than the projected rate (p = 0.06). Three of the 29 patients (10%) with heatable tumours had a LF, versus 1/5 unheatable tumours (p = 0.48). Fourteen of the 30 patients (47%) with heatable tumours developed DM, versus 2/5 unheatable tumours (p = 1.00). Ten of the 30 patients (33%) with heatable tumours developed treatment-induced toxicity. Thus, no correlation of thermal dose with histologic response was observed. Prospective control of CEM43 degrees T90 failed to achieve the projected pCR rate following pre-operative thermoradiotherapy for high-grade soft tissue sarcomas, despite excellent local control. Possible explanations for this outcome are discussed.

Nurse managed occupational health services without on-site clinical care delivery: a case example

1. In this program management/community network model of occupational health services, the occupational health nurse is responsible for managing program development and implementation, with vendors providing the clinical services. 2. Occupational health nurses' primary areas of responsibility are occupational health, disability case management, ergonomics, and health promotion. 3. Successful management of program outcomes requires the occupational health nurse to continually assess employee/business needs, maintain communication with employees and management, and partner with the environmental, health, and safety team, other functional work groups, and vendors. 4. Effective management of contracts becomes critical to the process beginning with clear service requirements through the delivery of quality services.

A competency-based model of child depression: a longitudinal study of peer, parent, teacher, and self-evaluations

In a two-wave longitudinal study of third and sixth graders (N = 617), we obtained self-reports of depression and peer, teacher, parent, and self-reports of competence in five domains: academic, social, attractiveness, conduct, and athletic. Competency evaluations by others predicted change in self-perceived competence over time for girls, but not for boys. Depression predicted change in self-perceived competence over time for boys but not for girls. Among girls, the relative importance of parent, teacher, and peer appraisals shifted from third to sixth grade. For both boys and girls, self-perceptions of competence predicted change in depression scores over time. Furthermore, self-perceived competencies mediated the relation between competency appraisals by others and children's self-reported depression. Results are interpreted in light of a competency-based model of child depression.

One-stage reconstruction of partial laryngopharyngeal defects

Advanced-stage lesions of the hypopharynx or tongue base often involve the larynx. The difficulty of reconstructing large partial laryngopharyngeal defects can result in total laryngectomy being performed to avoid the assumed problems with aspiration. This article describes the first reported experience using the pectoralis musculocutaneous flap for primary one-stage reconstruction of laryngopharyngeal defects following resection of advanced-stage lesions, to reconstruct both the laryngeal and the pharyngeal components of the defect. In this group of 21 patients, there were 16 with hypopharyngeal and 5 with tongue base cancers. Two had received prior treatment, and all received some form of postoperative radiotherapy and/or chemotherapy. Six patients experienced complications, including two fistulae, three wound infections, two myocardial infarctions, and one colon perforation. There were no instances of stenosis of the reconstructed segment. The length of hospitalization ranged from 9 to 60 days, the average being 17 days. Forty-seven percent (21) of the patients were not tolerating an oral diet at the time of discharge. However, 15 patients (71%) ultimately were eating by mouth, with 13 (62%) achieving an oral intake of liquids and solids. This analysis supports the hypothesis that the pectoralis major musculocutaneous flap is an effective one-stage primary reconstruction technique for laryngopharyngeal defects in patients either who have received prior therapy or who will receive postoperative therapy.

Modeling causal relations between academic and social competence and depression: a multitrait-multimethod longitudinal study of children

The authors obtained self-reports, peer nominations, teacher ratings, and parent reports of depression and social and academic competence on 490 3rd graders and 455 6th graders near the beginning and end of the school year. Confirmatory factor analysis and structural equation modeling revealed that (a) measures showed significant convergent and discriminant validity; (b) within-wave correlations between constructs were large and significant, although the depression-social competence correlation was larger than the depression-academic competence correlation; (c) the cross-wave stability of all constructs was remarkably high; and (d) social competence at Wave 1 predicted depression at Wave 2 for 6th graders after controlling for depression at Wave 1. Depression did not predict change in either academic or social competence over time. Implications for competence-based and failure-based models of child depression are discussed.

Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

It is unclear whether a partial or complete gastric fundoplication done laparoscopically will offer the best control of reflux with the fewest side effects. Prospective evaluation of laparoscopic Rosetti-Nissen (360) and Toupet (180) fundoplication was performed with assessment of clinical and manometric data.

METHODS

Patients with severe gastroesophageal reflux referred for surgical correction underwent preoperative motility and upper endoscopy. A Rosetti-Nissen or Toupet fundoplication was then performed laparoscopically. Short gastrics were not divided. No bougie was used in the Toupet, which was sutured intracorporeally. A 2-cm, loose, floppy wrap about a 50-Fr bougie was performed in the Nissen. Eleven patients underwent Rosetti-Nissen and 11 Toupet fundoplication. Mean ages, duration symptoms, weight, and baseline LES, were not different. Preop esophagitis grades were similar, as were Visick Scores and presence of dysphagia.

RESULTS

Visick scores at 6 months were better in the Toupet group than the Rosetti-Nissen (P = 0.07). Persistent Dysphagia in four, Gas-Bloat in two, and Odynophagia in one within the Rosetti-Nissen group accounted for the difference, and were not seen in Toupets. LES pressures differed significantly pre and postop (P < 0.001). The change in LES pressure was significantly different between Toupet and Rosetti-Nissen (chart). Seven patients had postop 24-h pH tests; all had no reflux. Three Rosettis have required revision to Toupet, with resolution of their symptoms.

CONCLUSIONS

In patients with severe GERD, laparoscopic Toupet and Rosetti-Nissen control symptoms and esophageal pH similarly. LES pressures are higher postop in the Rosetti-Nissen. Dysphagia and gas-bloat are more prevalent in the Nissen group. Laparoscopic Toupet fundoplication may be superior to Rosetti-Nissen in reducing the frequency of side effects frequently associated with antireflux surgery, yet with equal control of reflux.

Modeling causal relations between academic and social competence and depression: a multitrait-multimethod longitudinal study of children

The authors obtained self-reports, peer nominations, teacher ratings, and parent reports of depression and social and academic competence on 490 3rd graders and 455 6th graders near the beginning and end of the school year. Confirmatory factor analysis and structural equation modeling revealed that (a) measures showed significant convergent and discriminant validity; (b) within-wave correlations between constructs were large and significant, although the depression-social competence correlation was larger than the depression-academic competence correlation; (c) the cross-wave stability of all constructs was remarkably high; and (d) social competence at Wave 1 predicted depression at Wave 2 for 6th graders after controlling for depression at Wave 1. Depression did not predict change in either academic or social competence over time. Implications for competence-based and failure-based models of child depression are discussed.

Popliteal tendon transposition for stabilization of the cranial cruciate ligament deficient stifle joint in dogs: an experimental study

Popliteal tendon transposition was performed in five dogs with surgically induced cranial cruciate ligament rupture. After a lateral approach to the stifle joint, the popliteal tendon was severed distal to the sesamoid bone and transposed cranially onto the tibial crest to mimic the sagittal orientation of the cranial cruciate ligament. The origin of the popliteal tendon on the lateral femoral condyle was preserved. Lameness was not clinically detectable 2 months after surgery. At 6 months postoperatively, there was minimal radiographic and histopathologic evidence of degenerative joint disease in the stifle joints that had underwent surgery. There was no gross or microscopic evidence of meniscal damage found at necropsy 6 months after surgery. Biomechanical studies are warranted before recommending the procedure.

Thrombocytopenia post liver transplantation. Correlations with pre-operative platelet count, blood transfusion requirements, allograft function and outcome

This study reports that thrombocytopenia is a universal phenomenon post hepatic transplantation. In 53 consecutive adult patients undergoing liver transplantation the platelet count fell by a mean of 63% (157 x 10(9)/l to 50 x 10(9)/l). The platelet count reached a nadir at Day 5 post-transplant but returned to pre-operative levels by Day 14. Non-parametric regression analysis found that pre-operative platelet count, blood transfusion requirements and maximum post-operative ALT values were independent predictors of the percentage fall in platelet count. No correlation was seen with length of graft cold ischaemic time or the use of University of Wisconsin (UW) solution. The nadir day correlated with maximum post-operative bilirubin and ALT, graft ischaemic time and use of UW solution. Maximum post-operative ALT was also an independent predictor of nadir platelet count. It was observed that patients who did not survive the hospital admission had lower post-operative platelet counts and these did not return to pre-operative levels by Day 14. The percentage fall in platelet count was an independent predictor of survival. Severe thrombocytopenia was associated with cerebral haemorrhage in 3 patients. This report provides evidence that allograft dysfunction (maximum post-operative bilirubin and/or AST/ALT) was the most consistent independent predictor of the nadir platelet count, nadir day and percentage fall in platelet count post liver transplantation although the exact mechanism(s) of the platelet changes remain uncertain.

Benign solitary schwannoma of the foot. A case report and review of the literature

Benign solitary schwannomas of the foot are a rare occurrence; only four cases have been previously reported. A schwannoma associated with the medial plantar nerve present for more than 40 years before the onset of symptoms was diagnosed in a 73-year-old man. Excision of the mass, with preservation of the involved nerve, was possible and successfully relieved symptoms.

Thymoma detection by mediastinal CT: patient with myasthenia gravis

The precise role of computed tomography (CT) in evaluating the mediastinum for thymomas in patients with myasthenia gravis is not defined. The only published CT accuracy assessment reports a false-positive rate of 90%. Mediastinal CT was performed in 23 consecutive unselected patients with myasthenia gravis who underwent thymectomy independent of their neurologic status or diagnostic imaging results. Four patients had discrete thymomas; all were detected by CT. Conventional chest radiography and tomography were positive in three and falsely negative in one. In the remaining 19 patients with a normal or atrophic thymus or microscopic hyperplasia, CT was falsely positive in two; conventional chest radiography and tomography were falsely positive in three. Mediastinal CT is an accurate technique for evaluation of thymoma in patients with myasthenia gravis.

Survival of Campylobacter fetus subsp. jejuni in biological milieus

To provide new information on the epidemiology and pathophysiology of human infection with Campylobacter fetus subsp. jejuni, we studied its survival in several milieus. Standard inocula of organisms were placed in hydrochloric acid, human bile and urine, bovine milk, or stream water and kept at 4, 25, or 37 degrees C; viable organisms were then counted. Stools from humans infected with Campylobacter were similarly tested. Survival in acid was pH and time dependent, with 7-log kill within 5 min in solutions at pH 2.3. Organisms multiplied in bile at 37 degrees C and survived for 2 months. Organisms survived better in feces, milk, water, and urine kept at 4 degrees C than they did in these milieus at 25 degrees C. Maximal viabilities of Campylobacter organisms kept at 4 degrees C were 3 weeks in feces, 3 weeks in milk, 4 weeks in water, and 5 weeks in urine. Study results suggest that when these milieus are contaminated with C. fetus subsp. jejuni, they may be significant environmental reservoirs.

Traumatic anterior atlanto-occipital dislocation

The five cases of atlanto-occipital dislocation reported in the world literature are reviewed, and four additional cases are presented, including two survivors. The pathological anatomy of this potentially catastrophic injury and its management are briefly discussed. Because immediate recognition of the atlanto-occipital dislocation is critical to proper treatment and because the neurological findings are extremely varied, a new radiographic criterion for its identification has been developed.

Cervical spine trauma: the common combined conditions

The two most common groups of combined traumatic conditions of the cervical spine are hyperextension and hyperflexion fracture-dislocations. In a series of 400 patients with fractures and/or dislocations of the cervical spine, 25% had hyperextension and 19% hyperflexion fracture-dislocations. A computer analysis of the cases revealed that there are five distinct types of hyperextension and four types of hyperflexion fracture-dislocations. Each of the types is considered as to incidence, causes, mechanism of injury, and roentgen and differential diagnosis.

Sexual receptivity: facilitation by medial preoptic lesions in female rats

Lesions in the medial preoptic area of ovariectomized female rats reduced the quantity of estrogen needed to induce sexual receptivity in these animals. In addition, the number of days over which receptive behavior could be elicited after a single initial estrogen injection and with subsequent daily progesterone treatment was significantly increased by lesions in the medial preoptic area. These findings support the view that estrogen acts to reduce an inhibitory action that is tonically exerted by the medial preoptic area on pathways mediating estrous behavior.