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Classification of abnormal neurological outcome.

When we engage in the systematic follow-up of high-risk neonates it is important to avoid the temptation to assume that any variations in development in this population reflect 'abnormality.' In this chapter I first present some personal reflections and hobby horses to argue that we need to be aware of our possible biases toward interpreting developmental or functional differences in infants as evidence of developmental pathology. Second, I stress the challenges associated with making early 'diagnoses' of developmental disabilities. Instead I suggest that identification of differences and variations in development should be interpreted cautiously, taking account of natural variations in early development and the chance to observe children over time rather than needing to make a decision on the basis of a single assessment. Finally, I discuss cerebral palsy and illustrate the arguments I have presented with discussion of current thinking about diagnosis and classification of CP.

Cerebral Palsy↗

Successful treatment of deep sternal infections following open heart surgery by bilateral pectoralis major flaps.

OBJECTIVES: Severe sternum necrosis requiring extended resection necessitates plastic reconstruction of the resulting defect and stabilization of the chest. We analyzed the outcome of patients undergoing bilateral pectoralis major flap repair on functional and cosmetic results, chest stabilization and pulmonary function. METHODS: Twelve patients undergoing cardiac surgery between 1997 and 2001 suffered from a deep mediastinal wound infection and sternum necrosis. After a mean of two attempts of extensive wound debridement, all 12 patients underwent complete sternal resection with plastic reconstruction by bilateral pectoralis major flaps. Risk factors were obesity (n=10) and diabetes (n=11). Six months postoperatively patients underwent physical examination, pulmonary function testing and functional CT scan. RESULTS: Three patients died in hospital (two septic multiorgan failure, one heart failure) and nine were discharged with complete wound closure. One patient suffered a lethal stroke during follow-up. At 6-month follow-up no recurrent sternum infection had occurred. Chest stability was satisfactory without impairment of pulmonary function (VC 77.5+/-12.1% at follow-up vs 77.8+/-12.5% preoperatively). Mobility and force of arms and shoulder were adequate; at CT scan the maximum distance change between the former sternoclavicular joint in inspiration versus expiration was minimal. Quality of life questionnaires showed no significant limitations except a disturbed sleep and mild restriction of executing hobbies and social activities. CONCLUSIONS: Bilateral pectoralis major flap repair is a safe technique to cure severe mediastinitis necessitating complete sternal resection. Wounds close without extensive reconstructive surgery. Cosmetic results as well as stabilization of the chest were good. Patients reported an almost uncompromised quality of life without respiratory impairment.

Aged↗

Are there sex and gender differences in acute exposure to chemicals in the same setting?

We have little understanding of the influence that sex and gender may have on exposure to and measurement of occupational chemicals. If men and women are in the same physical environment, whether that be an occupational or an environmental setting, researchers need to question whether their acute exposure, as measured by administered and/or biologically effective dose, is the same. Not doing so may result in incorrect inferences being made about the risks associated with that exposure. Three critical questions arise specifically, do men and women differ in (1) their personal environments (immediate physical environments and personal attributes), (2) their absorption of the substance across the various biological barriers, and (3) the amount of active substance that reaches the target sites? Both contextual (e.g., smoking habits, diet, use of personal care products and jewellery, hobbies, stress, and use of medications) and biological (e.g., endocrine status) factors should be considered in answering these questions. Examples from the literature are provided to show that, depending on the chemical compound, there may be sex and gender differences in exposure to chemicals which can be manifested in sex differences in absorption, distribution, metabolism, storage, and excretion. An argument is developed to support the need to make information available, such as pharmacokinetic modeling studies in both men and women including appropriate age groups representing the spectrum of life stages and reproductive status.

Body Burden↗

Housing and health counselling: preliminary results of a new medical referral system in France.

STUDY OBJECTIVES: Since 2002, a new unique service is available to physicians in southeast France. They may ask for a housing environmental inspection for their patients when they feel that the indoor environment has a negative influence on health status. This telephone survey was designed to evaluate the efficacy of this service. DESIGN: During this time period, 328 such housing environmental inspections have been performed. The protocol of these inspections included a detailed questionnaire and environmental sampling for mold identification, mite-allergen evaluation and, in selected cases, measurement of volatile organic compounds (VOC). Inspections were performed by trained technicians. From April to September 2005, we performed a telephone interview survey, using a structured questionnaire, to evaluate the reported outcome. RESULTS: Main defects identified in houses were mold infestation (44%), mite contamination (32%), and VOC exposure (9%) from new furniture, repairs performed and hobbies. Substantial repairs, including carpentry, wall floors and ceilings repairs, mold decontamination, and plumbing, had been performed in 59.4% of those houses. Full compliance, partial compliance, and no compliance by the occupant with the recommendations provided by the housing environmental inspectors were 50%, 20%, and 30%, respectively. Reasons for non-compliance included moving, time, and money constraints. When rating the efficacy of the service, total, almost total, and partial effectiveness was reported by the families to be 3%, 31%, and 56%, respectively. CONCLUSION: This type of service holds great promise for patients as well as for physicians and should be investigated further by measuring physician-diagnosed health outcome and using cost-benefit analysis.

Air Pollution, Indoor↗

Disclosure decisions among known and anonymous oocyte donation recipients.

OBJECTIVE: The purpose of this study was to compare anonymous and known donor mothers' demographics, knowledge about the donor, and disclosure attitudes. DESIGN: Cross-sectional survey of oocyte donation parents. SETTING: Academic medical centers. PATIENT(S): Women having a child through oocyte donation in the past 12 years. INTERVENTION(S): Subjects completed a survey regarding their oocyte donation experience. MAIN OUTCOME MEASURE(S): Donor characteristics and disclosure behavior. RESULT(S): Questionnaires were sent to 524 individuals (262 couples); 157 (92 women and 65 men) were returned yielding a response rate of 31.4% (157/500). The average age of the women was 44.7 years and the average age of the child was 2.89 years. Seventy women used anonymous donors and 20 women used known donors. Significantly more known recipients knew their donors' religion, number of children, hobbies, profession, and photograph. Eighty percent of both groups told others about using a donor to conceive. Regarding telling the child, there were also no significant differences with approximately 10% who have told, 49% plan to tell, 31% are not telling, and 10% are unsure. CONCLUSION(S): Contrary to conventional wisdom we found no differences in plans to inform the child based on the use of a known or an anonymous donor.

Adult↗

Influences, usage, and outcomes of Internet health information searching: multivariate results from the Pew surveys.

This paper provides results from seven major nationally representative datasets (two in detail) from the Pew Internet and American Life Project to answer two primary questions: (1) what influences people to seek online health information and (2) what influences their perceived outcomes from having access to this information? Cross-tabulations, logistic regressions, and multidimensional scaling are applied to these survey datasets. The strongest and most consistent influences on ever, or more frequently, using the Internet to search for health information were sex (female), employment (not fulltime), engaging in more other Internet activities, more specific health reasons (diagnosed with new health problem, ongoing medical condition, prescribed new medication or treatment), and helping another deal with health issues. Internet health seeking is consistently similar to general Internet activities such as email, news, weather, and sometimes hobbies. A variety of outcomes from or positive assessments of searching for Internet health information are predicted most strongly by sex (female), engaging in other Internet activities, Internet health information seeking including more frequent health seeking, more specific health reasons, belonging to an online support group sharing health interests, and helping another deal with an illness or major health condition.

Adolescent↗

Depressive symptoms in middle-aged men: results from a household survey in Hong Kong.

BACKGROUND: To evaluate the prevalence and risk factors of depressive symptoms in middle-aged Chinese men aged 45-64. METHODS: A community-based cross-sectional household survey was performed in Hong Kong. Demographic, lifestyle and medical information were obtained from a standardized questionnaire. Clinically relevant depressive symptoms were measured by the Centre for Epidemiological Studies Depression Scale (CES-D). RESULTS: Five hundred forty five men participated in this study (response rate: 72.4%); 18.1% suffered from clinically depressive symptoms. For psychosocial factors in bivariate analyses, being divorced/separated/widowed, living alone, having an education level of primary school or less, having a low income, unemployment and having experienced a significant life event over the past year were associated with an increased odds of having depressive symptoms. In multiple regression analysis, living alone, being unemployed and having experienced a negative life event such as having experienced serious financial trouble, having given up a hobby or activity that was important to subject and having been separated from a child, close friend or relative were associated with increased odds of having clinically relevant depressive symptoms. LIMITATIONS: Although random sampling was performed, there might be a selection bias for men who were unemployed and at home at the time of the interview. CONCLUSIONS: Clinically relevant depressive symptoms are an important public health problem in Chinese middle-aged men particularly those who are unemployed, have a negative life events and live alone. As middle-aged men are at high risk for suicide, public health intervention should be targeted at these men.

Cohort Studies↗

Proximal interphalangeal joint stiffness: measurement and analysis.

PURPOSE: The purpose of this study was to quantify the stiffness of the human finger proximal interphalangeal (PIP) joint and to study its relationship to different common clinical parameters. METHODS: Eighty-nine normal adult subjects had their PIP joints of the index, middle, and ring fingers evaluated using a computer-controlled moment-angle plotter. This device was used to measure stiffness and energy absorbed at the PIP joint during passive flexion and extension. RESULTS: The average overall stiffness was 0.05 N-cm/degree. There was a weak correlation between stiffness and energy absorbed and the size of the finger: they both increased with the size of the finger. The men's fingers were stiffer and absorbed more energy than the corresponding women's fingers. No significant associations were found between the time of day when the test took place, occupation, hobbies, or age with stiffness or absorbed energy. No significant differences were associated with hand dominance. The finger on the dominant hand had a larger circumference for both genders. Heavier individuals had more stiffness and absorbed more energy than lighter individuals. CONCLUSIONS: The PIP joint stiffness was defined quantitatively and measured over a wide cross-section of a normal population. This may allow future studies to record the outcome of different treatments for finger joint stiffness objectively. The stiffness was greater in men and in larger fingers.

Adult↗

The significance of extensor tendon tethering and dorsal joint capsule tightening after injury to the hand.

This paper examines the clinical problem of extensor tendon tethering and/or dorsal joint capsule tightening secondary to hand injury. One hundred and forty-one patients were examined 13 to 51 months after hand injuries of varying severity. Fifty-six patients (40%) had suffered simple and eighty-five patients (60%) complex injuries. Seventy-four (52%) of the 141 patients had no extensor tendon tethering and/or dorsal joint capsule tightening. In 30 (21%), the extensor tendon tethering and/or dorsal joint capsule tightening was considered to be "obvious" in that it was easily seen on examination using various commonly used clinical tests of finger flexion and extension. In 37 (26%), the extensor tendon tethering and/or dorsal joint capsule tightening was considered to be of "lesser degree" because it was only evident on application of specific tests which are described in this paper. Of the 37, 21 (56%) described themselves as being unable to make a "proper" fist with the injured hand, 33 (89%) had pain or discomfort on the dorsum of the injured hand and/or fingers on gripping (P < 0.01) and 25 (70%) had weakness of power of gripping (P < 0.01). Thirty-two (87%) complained of functional problems at work, with activities of daily living or with the pursuit of their hobbies.

Activities of Daily Living↗

MR imaging of ligaments and triangular fibrocartilage complex of the wrist.

Imaging of the wrist with MR imaging can be difficult because of the small size of this joint, its complex anatomy, and its sometimes poorly understood pathologic lesions. A recent study by Hobby and coworkers of 98 patients revealed that MR imaging of the wrist influences clinicians' diagnoses and management plans in most patients. This article summarizes the current diagnostic criteria that can be useful in interpreting abnormalities of the wrist ligaments and triangular fibrocartilage complex (TFCC) of the wrist in this difficult topic in joint MR imaging.

Carpal Bones↗

The effect of lead on the avian auditory brainstem.

Lead (Pb) continues to be a significant environmental toxin and remains an integral part of many industrial processes, hobbies, and tobacco smoke. Pb has been shown to be a potent toxin to the CNS and low levels of Pb (below the CDC established toxic blood level of 10 microg/dl) have been correlated with decreases in the IQ of children. Pb exposure is a risk factor for dyslexia, and significantly, dyslexics have deficits in auditory temporal processing, including backward masking and amplitude modulation detection. Importantly, Pb-exposed children have been found to be deficient in various aspects of auditory temporal processing, including backward masking. Auditory temporal information is vital for appropriate speech detection and it is not known where within the auditory axis temporal processing takes place, nor is it understood how Pb exposure modifies the cells of the auditory system. To address these questions, we have developed an animal model of auditory temporal processing using chickens and have established that Pb exposure during development results in deficits in backward masking in avians. The current study was undertaken to identify the cellular changes induced by Pb exposure in the auditory brainstem of chickens that are likely anatomical correlates of the observed deficits in backward masking. We found Pb exposure had no effect on neuron number or glial cells within the auditory brainstem. However, Pb exposure does result in significant decreases in the amount of the medium weight neurofilament protein (NFM) as well as decreased NFM phosphorylation within the axons connecting auditory nuclei in the avian brainstem. Because the amount of neurofilament can affect the conduction velocities of axons, these results may provide an anatomical link between Pb exposure, auditory temporal processing deficits, and dyslexia.

Animals↗

Patients experience with long-term percutaneous endoscopic gastrostomy feeding following primary surgery for oral and oropharyngeal cancer.

Percutaneous endoscopic gastrostomy feeding (PEG) has an important role in providing nutritional support in selected patients undergoing treatment for oral and oropharyngeal cancer. Although morbidity data have been published there is very little from the patient perspective. The aim of this project was to devise, pilot and survey a PEG specific questionnaire and relate outcomes to health-related quality of life. A cross-sectional survey was conducted in April 2005 of patients who were alive and disease free and treated by primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and June 2004. The survey comprised the University of Washington Quality of Life questionnaire and a 24 item PEG questionnaire. Of 344 alive and disease free patients, 243 (71%) responded. Clinical characteristics of responders and non responders were similar. Mean age of responders was 65 (SD 12) and 59% were male. There were 193 (79%) patients who never had a PEG as part of their treatment, 30 (12%) who had their PEG removed (median 7 months), and 20 (8%) who still had a PEG (median 34 months). Patients with PEGs reported significant deficits in all UW-QOL domains compared to non-PEG or PEG-removed patients and also reported a much poorer quality of life. The major PEG related problems were not those of discomfort, leakage or blockage, but interference with family life, intimate relationships, social activities, and hobbies. More can be done to counsel and support patients with long-term PEG placement.

Aged↗

Usual drinking patterns and non-fatal injury among patients seeking emergency care.

OBJECTIVES: To explore the association between drinking patterns, irrespective of whether alcohol was consumed in the event of the injury or not, and different injury variables; and to identify settings and situations in which risky drinkers have an increased likelihood of injury. STUDY DESIGN: The study population consisted of all patients aged 18-70 years registered for an injury according to ICD-10 at a Swedish emergency department during an 18-month period. After informed consent, the injury patients were screened for drinking habits by the AUDIT-C questionnaire. The gender, age and drinking pattern of injury patients were compared with the general population. METHODS: A total of 2782 patients aged 18-70 years were registered for an injury during the study period. The number of drop-outs was 631. Drop-outs include those who did not consent to participate, were severely injured, too intoxicated or did not fill out the questionnaire satisfactory. Thus, 77.3% of the target group were included for further analysis (1944 drinkers and 207 abstainers). The patients were categorized into three drinking categories: abstainers, non-risky and risky drinkers. Risky drinkers were defined according to usual weekly consumption of 80g or more of alcohol for women and 110g or more for men and/or heavy episodic drinking (i.e. having six glasses or more one glass=12g alcohol), or both, on one occasion at least once a month, valid for both women and men. To estimate the relationship between drinking patterns and the injury variables (environment, cause of injury, activity and diagnosis), odds ratios (OR) were calculated by logistic regression. Multiple logistic regression was used in order to control for age and sex differences between the various drinking and injury categories. RESULTS: The proportion of risky drinkers was higher in the study population compared with the general population in the same area. When controlling for age and sex, risky drinkers (OR 6.4(adj) Confidence interval CI 1.9-21.2) and non-risky drinkers (OR .4.5(adj) CI 1.4-14.5) displayed an increased risk for injury compared with abstainers, in amusement locations, parks, by or on lakes or seas, especially while engaged in play, hobby or other leisure activities (risky drinkers: OR 2.8(adj) CI 1.3-5.6; non-risky drinkers: OR 2.4(adj) CI 1.2-4.6). All differences between drinking patterns in external cause of injury disappeared when age and sex were considered. During rest, meals and attending to personal hygiene, the non-risky drinkers had a lower probability of injury compared with abstainers (OR 0.3(adj) CI 0.1-0.8). Non-risky drinkers had a higher probability than abstainers of suffering luxation (dislocation) or distortion (OR 1.6(adj) CI 1.1-2.5). Nine per cent of the study population reported that they believed that their injury was related to intake of alcohol. Half of this group were non-risky drinkers (CI for the 13.7% difference was 9.7-17.6). CONCLUSIONS: Few significant associations between drinking pattern and injury remained when age and sex were controlled for.

Adolescent↗

MR imaging of ligaments and triangular fibrocartilage complex of the wrist.

Imaging of the wrist with MR imaging can be difficult because of the small size of this joint, its complex anatomy, and its sometimes poorly understood pathologic lesions. A recent study by Hobby and coworkers of 98 patients revealed that MR imaging of the wrist influences clinicians' diagnoses and management plans in most patients. This article summarizes the current diagnostic criteria that can be useful in interpreting abnormalities of the wrist ligaments and triangular fibrocartilage complex (TFCC) of the wrist in this difficult topic in joint MR imaging.

Humans↗

Perceived change in quality of life during the menopause.

The directly attributable effect of menopausal transition on women's quality of life (QoL) remains unclear. This study investigates the relationship between perceived change in QoL and menopausal transition status, socio-economic circumstances, lifestyle factors, and life stress. Prospective data were collected from a cohort of 1525 British women followed up since their birth in 1946 and annually from 47 to 54 years. Following factor analysis, the 10 survey items for perceived change were combined into three QoL domains: physical health (physical health, energy level, and body weight), psychosomatic status (nervous and emotional state, self-confidence, work life, ability to make decisions, and ability to concentrate), and personal life (family life and time for self, hobbies, and interests). In the fully adjusted model, the most important risk factor for decline in all three domains was work or family related stress (p<0.001). Menopausal transition status was significantly associated with change in physical health (p<0.001) and psychosomatic (p<0.001) domains, but not personal life. Women who were perimenopausal for at least a year perceived decline in physical (p=0.009) and psychosomatic (p=0.05) domains compared with premenopausal women, while those on hormone replacement therapy (HRT) for at least a year reported relative improvement (physical p=0.02, psychosomatic p=0.06). Apart from work and family-related stress, physical inactivity was associated with a relative decline (p=0.03) in the physical health domain, and nulliparity with a relative decline in the personal life domain (p=0.006). Both psychosomatic and personal life domains declined significantly with age (p<0.0001 and p=0.003, respectively). Women with four or more children reported a relative improvement in the psychosomatic (p=0.05) domain. In terms of the three QoL domains, women's experience of the menopausal transition appears complex, potentially involving a range of other factors and influences in their lives, and is by no means overwhelmingly negative.

Female↗

Envenoming by the viperid snake Eristicophis macmahonii.

Little is known about the effects of bites by the rare viperid snake Eristicophis macmahonii. A 31-year-old Belgian man, who keeps these animals as a hobby, was bitten on a finger by one of his pets while trying to give it some medicine. The patient developed syncope, followed by a sudden extensive skin rash and massive edema of the arm. He recovered completely, except for a small area of limited tissue necrosis on the bitten finger.

Adult↗

An investigation of the prevalence of depressive symptoms in soldiers during military training.

OBJECTIVES: A cross-sectional study was conducted to determine the prevalence of depressive symptoms in soldiers during military training in Chinese army and to identify associations between depressive symptoms and socio-demographic characteristics. METHODS: The self-rating depression scale (SDS) was used to assess self-reported experiences of depression among 1107 young adult males during military training. The following socio-demographic variables are considered as independent variables: age, service time, settlement type, education, levels of family income, family type, education of parents, health status, history of negative accidents, social support status and hobby status. A logistic regression model was used to estimate the association of these variables with depressive symptoms. RESULTS: 25.20% (n = 279) of the servicemen had depressive symptoms. The soldiers who had high education level (OR = 1.74; 95%CI: 1.37-2.12), come from city or town (OR = 1.39; 95%CI: 1.18-1.61), have served in army for a shorter time (OR = 1.63; 95%CI: 1.43-1.88), had head ache during training course (OR = 1.39; 95%CI: 1.12-2.09), had abdomen ache or diarrhea during training course (OR = 1.85; 95%CI: 1.47-2.13) and had training injury during training course (OR = 1.67; 95%CI: 1.29-1.83) are associated with depressive symptoms. CONCLUSIONS: There was a high prevalence rate of depressive symptoms among soldiers during military training. Special attention should be paid to avoiding depressive symptoms in those who have high education level, come from city or town, have served in army for a shorter time and have health problems during training course.

Adolescent↗

A rational approach to wound difficulties after sternotomy: reconstruction and long-term results.

One hundred fifty-one patients were reconstructed after median stemotomy by a single plastic surgeon over a 6-year period. The treatment included immediate reconstruction (63 patients) and delayed reconstructions (88 patients). Ninety eight percent of the patients had definitive healing at 6 weeks with an overall 30-day mortality of 4 percent. The issues of long-term intravenous antibiotics, perceived skin deficiency, cardiac decompensation, Candida infections, and reexploration of a healed mediastinum after flap reconstruction are discussed. Follow up (4 months to 6 years) of patients treated with reconstruction compared favorably with patients treated with rewiring procedures (20 patients) in regard to strength, chest wall stability, pulmonary function testing, and functional return to hobbies and employment.

Adult↗