The Proxy Model of Social Comparison for Self-Assessment of Ability

One purpose of the social comparison of abilities is to determine action possibilities— “Can I do X?” By comparing ourselves with a proxy who has attempted X, we can determine our likelihood of success. A good proxy is one who has performed the same as us on an initial task requiring the ability. In addition, however, a good proxy must be similar on related attributes so that we can be confident that the proxy's performance on the initial task was maximal. In the case of a task requiring multiple abilities, more than one proxy may be used.

Effect of Compliance Counseling on Brace Use and Success in Patients with Adolescent Idiopathic Scoliosis

BACKGROUND

Outcomes of orthotic management of idiopathic scoliosis depend on patient compliance with brace wear. The purpose of this study was to determine if counseling based on objective compliance data increases brace wear and therefore reduces the likelihood of surgery.

METHODS

Two hundred and twenty-two patients with adolescent idiopathic scoliosis were prospectively enrolled in a study to determine if physician counseling based on data obtained from compliance monitors (sensors embedded in the brace) improves brace use and decreases curve progression. Patients were placed into two groups. In the counseled group, patients were aware of the compliance monitor in the brace and were counseled at each visit regarding downloaded brace-usage data. The patients in the noncounseled group were not told the purpose of the monitor in their brace, and the compliance data were not made available to the physician, orthotist, or patient.

RESULTS

Ninety-three patients who were counseled with use of the compliance data and seventy-eight patients who were not so counseled completed bracing or underwent surgery; twenty-five patients were lost to follow-up before completing brace treatment, and twelve were still undergoing brace treatment at the time of the study review. The average curve magnitude at the initiation of bracing was 33.2° in the counseled group and 33.9° in the noncounseled group (p = 0.21 [not significant]). Patients in the counseled group wore their orthosis an average of 13.8 hours per day throughout their management, while noncounseled patients wore their brace an average of 10.8 hours per day (p = 0.002). Of the counseled patients who finished brace treatment, 59% did not have curve progression of ≥6°, whereas 25% had progression to ≥50° or to surgery. In the noncounseled group, 46% did not have curve progression of ≥6°, whereas 36% had progression to ≥50° or to surgery. Noncounseled patients who had curve progression to a magnitude requiring surgery wore their brace an average of 9.6 hours per day compared with 12.6 hours per day for the counseled patients who required surgery. The amount of daily brace wear by children who did not have curve progression to a magnitude requiring surgery was significantly greater than that by children who did require surgery (p = 0.029).

CONCLUSIONS

Providing patients undergoing bracing for adolescent idiopathic scoliosis with feedback about their compliance with brace wear improves that compliance. Patients who wore their brace more hours per day had less curve progression. Patients in both groups who had curve progression to a magnitude requiring surgery wore their brace less than their counterparts for whom bracing was successful. Compliance monitoring and counseling based on that monitoring should become part of the clinical orthotic management of patients with adolescent idiopathic scoliosis.

Soft tissue release and bilobed flap for severe radial longitudinal deficiency

PURPOSE

To report the hand position, range of motion, functional results, and radiographic outcomes associated with treating radial longitudinal deficiency with release of constricting or deforming soft tissue and resurfacing of the radial skin deficiency with a bilobed flap.

METHODS

We recalled and reviewed patients with at least a 3-year follow-up who had undergone soft-tissue release and coverage with a bilobed flap. The study group consisted of 16 patients and 18 wrists. All patients underwent follow-up examination and radiographs. Outcome measures using Pediatric Outcomes Data Collection Instrument (PODCI), Disabilities of the Arm, Shoulder, and Hand (DASH), and visual analogue scale (VAS) scores were recorded.

RESULTS

At a mean of 9.2 years follow-up, the average final resting wrist radial deviation angle was 64° compared with 88° preoperatively. The average active wrist flexion-extension arc was 73°. Average DASH score was 27 (range, 5-54). PODCI global was 88 (range, 75-97), PODCI happiness was 86 (range, 70-100), and VAS overall satisfaction (range, 0-10) was 1.2 (range, 0-8). At final follow-up, no physeal growth arrests were noted on radiographs, and no patients to date have required ulnocarpal arthrodesis.

CONCLUSIONS

Soft-tissue release and coverage with a bilobed flap should be considered in the treatment algorithm for patients with radial longitudinal deficiency. Outcome measures show that these patients maintain useful active motion, and along with their parents, are satisfied with both the appearance and function. Some recurrence of radial deviation was noted, which was similar to results previously reported following centralization/radialization procedures, although with a lower inherent risk of both physeal injury to the ulna and stiffness. In addition, potential future procedures are not compromised by this surgical approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Carpal Wedge Osteotomy in the Arthrogrypotic Patient

Introduction

Carpal wedge osteotomy in an arthrogrypotic patient repositions the wrist in neutral alignment while preserving available wrist motion.

Step 1 Mark the Locations of the Incisions

The location of the incisions allows excellent exposure of the wrist on both the volar and the dorsal surface.

Step 2 Release Tight Palmar Structures

After making the incision, carefully assess tight flexor structures and perform release and/or lengthening as appropriate.

Step 3 Dorsal Exposure

Make a dorsal transverse skin incision at the level of the carpus to allow identification and preservation of whichever thumb, finger, and wrist extensors are present.

Step 4 Carpal Osteotomy

After careful exposure of the carpus, make the proximal and distal osteotomy cuts and then evaluate the resulting wrist position and stabilization.

Step 5 Transfer the Extensor Carpi Ulnaris Tendon

Pass the extensor carpi ulnaris tendon to the radial wrist extensors and suture the tendon to the extensors.

Step 6 Postoperative Care

Cast immobilization for six to eight weeks is followed by splinting for six months.

Results

Our recently published study of patients with amyoplasia who underwent carpal wedge osteotomy showed that the corrected position was maintained and the individuals were satisfied with the results over the long term.IndicationsContraindicationsPitfalls & Challenges.

Long-term outcomes following radial polydactyly reconstruction

PURPOSE

To report long-term outcomes (> 10 y) after radial polydactyly reconstruction.

METHODS

We evaluated 43 surgically reconstructed thumbs in 41 patients with radial polydactyly whom we had observed for more than 10 years. The study group included 12 Flatt type II, 8 type III, 17 type IV, and 6 type V. The average age of surgery was 1 year and mean follow-up was 17 years. Objective outcome values and validated patient-oriented outcome evaluations were obtained.

RESULTS

No early postsurgical complications were encountered. Eight patients had 10 revision procedures at an average of 8 years after the initial procedure. Five patients had interphalangeal joint arthrodesis, all for angulation with accompanying pain. The average Tada score was 4.1. Lateral, tripod, and tip pinch strengths were 96%, 86%, and 92%, respectively, of the unaffected side. As a group, the treated thumbs had significantly weaker tip and tripod pinch strengths than the untreated thumbs. The average Disabilities of the Arm, Shoulder, and Hand score was 4.5 and the average Pediatric Quality of Life Inventory score was 87 when administered to both the patient and the parent.

CONCLUSIONS

Long-term results after surgical reconstruction for radial polydactyly were excellent but the revision rate trended upward over time despite maintenance of favorable scores on the objective outcome measures used.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Infants' scanning of dynamic faces during the first year

This research investigated infants' scanning of a talking, socially engaging face. Three- to four-month-olds looked equally at the mouth and eyes whereas 9-month-olds attended more to the eyes than mouth. These findings shed light on information infants' seek from dynamic face stimuli.

Long-term outcome following carpal wedge osteotomy in the arthrogrypotic patient

BACKGROUND

Wrist flexion and ulnar deviation deformity is a common presentation in children with amyoplasia congenita. Multiple surgical procedures have been reported to correct the deformity to enhance functional independence and improve quality of life. We performed a retrospective review to detail our long-term results with carpal wedge osteotomy in these patients.

METHODS

Medical records of all patients with the amyoplasia form of arthrogryposis who underwent carpal wedge osteotomy between 1994 and 2008 were reviewed. Patients with a follow-up of two years or less were excluded. Preoperative and postoperative resting position and range of motion of the wrist were recorded. Interviews and questionnaires were completed to assess the mean overall satisfaction level of the parent or guardian with the outcome of surgery, function, and task completion with use of parent-guardian surveys, the Manual Ability Classification System, and the ABILHAND-Kids measure of manual ability.

RESULTS

Seventy-five wrists in forty-six patients who met the inclusion criteria were reviewed. The average age of the patients at the time of surgery was 4.3 years (range, nine months to eighteen years; median, 2.7 years). The average duration of follow-up was 5.7 years (range, two to 10.3 years; median, 5.3 years). The average resting position of the wrist postoperatively (11° of flexion) was significantly different from that measured preoperatively (55° of flexion) (p < 0.001). The arc of wrist motion measured preoperatively (32°) did not differ significantly from that measured postoperatively (22°) (p = 0.4903). The location of the motion arc was significantly improved to a more functional position. The average active extension of the wrist changed from -37° of extension preoperatively to -11° of extension postoperatively (p < 0.001). Active wrist flexion also significantly changed from 69° preoperatively to 33° postoperatively (p < 0.001). Parent-guardian surveys indicated that the mean overall satisfaction score after surgery was 9.1 of 10 possible points and that the mean ranking for task completion in activities of daily living was 4 (easier following surgery).

CONCLUSIONS

Long-term outcomes reveal that surgical correction of wrist flexion posture in children with amyoplasia congenita results in improvement that is sustained over time. The surveys and questionnaires completed by parents or guardians indicated that they were satisfied with the results of the operation.

Volar ligament release and distal radial dome osteotomy for the correction of Madelung deformity: long-term follow-up

BACKGROUND

Madelung deformity is a disorder of growth of the distal aspect of the radius that is usually recognized in late adolescence near skeletal maturity. It results in a characteristic wrist deformity, decreased wrist motion, and wrist pain. The purpose of this study was to evaluate long-term results in patients treated by volar ligament release and distal radial dome osteotomy for Madelung deformity.

METHODS

Patients who had undergone volar ligament release and dome osteotomy for Madelung deformity at our institution from 1990 to 2002 and who were the subjects of a previous report on this treatment were contacted for clinical and radiographic evaluation at mid-term to long-term follow-up. Forearm and wrist motion was evaluated. Posteroanterior and lateral radiographs of both forearms were assessed for radial inclination, lunate subsidence, and arthritis changes. A Disabilities of the Arm, Shoulder and Hand (DASH) survey was completed.

RESULTS

Twenty-seven patients underwent volar ligament release and distal radial dome osteotomy. Eight patients were either lost to follow-up or were unable to return for follow-up. Nineteen patients with thirty-one operatively treated wrists were available for follow-up. After further review, eighteen patients and twenty-six wrists were included in the study. The average age at the time of follow-up was twenty-five years (range, nineteen to thirty-one years), with an average length of follow-up of eleven years (range, seven to fourteen years). There was no change in radial inclination or in wrist motion between the immediate postoperative and long-term follow-up evaluations. There was a positive correlation between the amount of deformity correction based on more severe preoperative parameters and an increased arthritic grade at the time of follow-up. There was positive correlation between an increased DASH score and arthritis grade as well as a correlation between whole bone deformity and increased arthritis grade and DASH score.

CONCLUSIONS

Volar ligament release and distal radial dome osteotomy for Madelung deformity provides lasting correction of the deformity. Long-term follow-up shows maintenance of original radiographic correction with good to excellent functional outcome. Patients with radiographic evidence of more severe disease preoperatively and the whole bone variety of Madelung deformity have poorer radiographic outcomes and trend toward poorer functional outcomes.

Sex differences during visual scanning of occlusion events in infants

A growing number of sex differences in infancy have been reported. One task on which they have been observed reliably is the event-mapping task. In event mapping, infants view an occlusion event involving 1 or 2 objects, the occluder is removed, and then infants see 1 object. Typically, boys are more likely than girls to detect an inconsistency between a 2-object occlusion event and a 1-object display. The current research investigated underlying reasons for this sex difference. Three eye-tracking experiments were conducted with infants at 9 and 4 months (mean age). Infants saw a ball-box or ball-ball occlusion event followed by a 1-ball display; visual scanning of the occlusion event and the 1-ball display was recorded. Older boys were more likely than older girls to visually track the objects through occlusion and more likely to detect an inconsistency between the ball-box event and the 1-ball display. In addition, tracking objects through occlusion was related to infants' scanning of the 1-ball display. Both younger boys and girls failed to track the objects through occlusion and to detect an inconsistency between the ball-box event and the 1-ball display. These results suggest that infants' capacity to track objects through occlusion facilitates extraction of the structure of the initial event (i.e., the number of distinct objects involved) that infants can map onto the final display and that sex differences in the capacity emerge between 4 and 9 months. Possible explanations for how the structure of an occlusion event is extracted and mapped are considered.

Evidence for cell fusion is absent in vascular lesions associated with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a fatal disease associated with severe remodeling of the large and small pulmonary arteries. Increased accumulation of inflammatory cells and apoptosis-resistant cells are contributing factors. Proliferative apoptosis-resistant cells expressing CD133 are increased in the circulation of PAH patients. Circulating cells can contribute to tissue repair via cell fusion and heterokaryon formation. We therefore hypothesized that in the presence of increased leukocytes and CD133-positive (CD133(pos)) cells in PAH lung tissue, cell fusion and resulting genomic instability could account for abnormal cell proliferation and the genesis of vascular lesions. We performed analyses of CD45/CD133 localization, cell fusion, and proliferation during late-stage PAH in human lung tissue from control subjects and subjects with idiopathic (IPAH) and familial (FPAH) PAH. Localization, proliferation, and quantitation of cell populations in individual patients were performed by immunolocalization. The occurrence of cellular fusion in vascular lesions was analyzed in lung tissue by fluorescence in situ hybridization. We found the accumulation of CD45(pos) leukocytic cells in the tissue parenchyma and perivascular regions in PAH patients and less frequently observed myeloid cells (CD45/CD11b). CD133(pos) cells were detected in occlusive lesions and perivascular areas in those with PAH and were more numerous in those with IPAH lesions than in FPAH lesions. Cells coexpressing CD133 and smooth muscle alpha-actin were occasionally observed in occlusive lesions and perivascular areas. Proliferating cells were more prominent in IPAH lesions and colocalized with CD45 or CD133. We found no evidence of increased ploidy to suggest cell fusion. Taken together, these data suggest that abnormal lesion formation in PAH occurs in the absence of cell fusion.

[Consequences of glaucoma on circadian and central visual systems]

Glaucoma is a chronic optic neuropathy leading to a degeneration of retinal ganglion cells. There is accumulating evidence that glaucomatous damage extends from retinal ganglion cells to vision centers in the brain. Degenerative changes are observed in magnocellular, parvocellular, and koniocellular pathways in the lateral geniculate nucleus, and these changes are related to intraocular pressure and the severity of optic nerve damage. In addition, recent studies show that there are also changes in the visual cortex in relation to varying degrees of retinal ganglion cell loss. In a rat model of glaucoma, we have recently demonstrated a reduction of retinal projections of retinal ganglion cells, not only on the visual system but also on the suprachiasmatic nucleus. Human studies suggest that the ganglion cell degeneration caused by glaucoma could lead to a lesion of the retinohypothalamic tract, which permits the synchronization of circadian rhythms.

Characterization of prolyl iminopeptidase-deficient Neisseria gonorrhoeae

Prolyl iminopeptidase (PIP) is an enzyme produced by Neisseria gonorrhoeae, the detection of which is incorporated into several commercial test panels. In this report we describe two distinct mutations in the pip gene which account for the loss of PIP activity.

Mutation in the gene for bone morphogenetic protein receptor II as a cause of primary pulmonary hypertension in a large kindred

BACKGROUND

Most patients with primary pulmonary hypertension are thought to have sporadic, not inherited, disease. Because clinical disease develops in only 10 to 20 percent of persons carrying the gene for familial primary pulmonary hypertension, we hypothesized that many patients with apparently sporadic primary pulmonary hypertension may actually have familial primary pulmonary hypertension.

METHODS

In a study conducted over 20 years, we developed a registry of 67 families affected by familial primary pulmonary hypertension. Through patient referrals, extensive family histories, and correlation of family pedigrees, we discovered shared ancestry among five subfamilies. We established the diagnosis of primary pulmonary hypertension by direct evaluation of patients and review of autopsy material and medical records. We assessed some family members for mutations in the gene encoding bone morphogenetic protein receptor II (BMPR2), which has recently been found to cause familial primary pulmonary hypertension.

RESULTS

We linked five separately identified subfamilies that included 394 known members spanning seven generations, which were traced back to a founding couple in the mid-1800s. Familial primary pulmonary hypertension has been diagnosed in 18 family members, 12 of whom were first thought to have sporadic disease. The conditions of 7 of the 18 were initially misdiagnosed as other cardiopulmonary diseases. Six members affected with familial primary pulmonary hypertension and 6 of 10 at risk for carriage have been undergone genotype analysis, and they have the same mutation in BMPR2, a transversion of thymine to guanine at position 354 in exon 3.

CONCLUSIONS

Many cases of apparently sporadic primary pulmonary hypertension may be familial. Failure to detect familial primary pulmonary hypertension results from incomplete expression within families, skipped generations, and incomplete family pedigrees. The recent discovery of mutations in BMPR2 should make it possible to identify those with susceptibility to disease.

Clinical and molecular genetic features of pulmonary hypertension in patients with hereditary hemorrhagic telangiectasia

BACKGROUND

Most patients with familial primary pulmonary hypertension have defects in the gene for bone morphogenetic protein receptor II (BMPR2), a member of the transforming growth factor beta (TGF-beta) superfamily of receptors. Because patients with hereditary hemorrhagic telangiectasia may have lung disease that is indistinguishable from primary pulmonary hypertension, we investigated the genetic basis of lung disease in these patients.

METHODS

We evaluated members of five kindreds plus one individual patient with hereditary hemorrhagic telangiectasia and identified 10 cases of pulmonary hypertension. In the two largest families, we used microsatellite markers to test for linkage to genes encoding TGF-beta-receptor proteins, including endoglin and activin-receptor-like kinase 1 (ALK1), and BMPR2. In subjects with hereditary hemorrhagic telangiectasia and pulmonary hypertension, we also scanned ALK1 and BMPR2 for mutations.

RESULTS

We identified suggestive linkage of pulmonary hypertension with hereditary hemorrhagic telangiectasia on chromosome 12q13, a region that includes ALK1. We identified amino acid changes in activin-receptor-like kinase 1 that were inherited in subjects who had a disorder with clinical and histologic features indistinguishable from those of primary pulmonary hypertension. Immunohistochemical analysis in four subjects and one control showed pulmonary vascular endothelial expression of activin-receptor-like kinase 1 in normal and diseased pulmonary arteries.

CONCLUSIONS

Pulmonary hypertension in association with hereditary hemorrhagic telangiectasia can involve mutations in ALK1. These mutations are associated with diverse effects, including the vascular dilatation characteristic of hereditary hemorrhagic telangiectasia and the occlusion of small pulmonary arteries that is typical of primary pulmonary hypertension.

Efficacy and Safety of Memantine, an NMDA-Type Open-Channel Blocker, for Reduction of Retinal Injury Associated with Experimental Glaucoma in Rat and Monkey

Glutamatergic excitotoxicity has been implicated as a mechanism for injury in a variety of central nervous system pathologies, including glaucoma. Memantine, an NMDA-type glutamatergic open-channel blocker, has pharmacologic properties that make its efficacy greater under excitotoxic conditions, but lesser under normal conditions. Daily oral dosing for approximately 15 months with 4.0 mg/kg memantine in monkeys yielded plasma concentrations similar to those found in patients who received memantine treatment for Parkinson's disease. This same dose of memantine was not associated with any evidence of an effect on the normal function of the retina and central visual pathways, as indicated by measures of the electroretinogram (ERG) and visually-evoked cortical potential (VECP). Amplitude of the VECP response was reduced in eyes with experimentally induced glaucoma. When compared to vehicle-treated control animals, memantine-treated glaucoma eyes suffered significantly less reduction of VECP amplitude. Preliminary results in a rat model for experimental glaucoma also show that, when compared to control animals, systemic treatment with memantine (10 mg/kg/day) was associated with a significant reduction in glaucoma-induced loss of retinal ganglion cells.

Exploring the potential for subtype-selective muscarinic agonists in glaucoma

Pilocarpine has been used to lower intraocular pressure (IOP) in glaucoma patients for more than 100 years. Since the identification of five muscarinic receptor subtypes, there has been an interest in separating the IOP-lowering effects from the ocular side effects of pupil constriction and lens accommodation. However, all these actions seem to be mediated by the M3 receptor. A novel muscarinic receptor agonist, AGN 199170, that has no activity on the M3 subtype was compared to pilocarpine in a monkey glaucoma model. This compound lowered IOP suggesting that muscarinic agonists targeted at muscarinic receptors other than the M3 subtype may be able to selectively lower IOP.

Biomechanics of ankle and hindfoot injuries in dynamic axial loading

Twenty-three Post Mortem Human Surrogate (PMHS) limbs were impacted using a test set up that was developed to simulate the loading conditions seen in a frontal collision. Articulation studies were performed on each limb prior to impact. Failure occurred at impact loads of 5.7+/-1.9 kN (resultant tibial failure load 6.4+/-1.9 kN) and the following injuries were generated: 9 intra-articular calcaneal fractures; 1 talar neck and 2 talar body fracture; 3 intra-articular distal tibial (pilon) fractures; 2 malleolar fractures; 3 soft tissue injuries and 3 had no detectable injury. The impact test conditions were replicated with a Hybrid III leg in a first attempt at developing injury risk functions for the dummy. This study has demonstrated the significance of preload through muscle tension and the intrinsic properties of PMHS specimens in the generation of severe ankle and hindfoot injury.

Sporadic primary pulmonary hypertension is associated with germline mutations of the gene encoding BMPR-II, a receptor member of the TGF-beta family

BACKGROUND

Primary pulmonary hypertension (PPH), resulting from occlusion of small pulmonary arteries, is a devastating condition. Mutations of the bone morphogenetic protein receptor type II gene (BMPR2), a component of the transforming growth factor beta (TGF-beta) family which plays a key role in cell growth, have recently been identified as causing familial PPH. We have searched for BMPR2 gene mutations in sporadic PPH patients to determine whether the same genetic defect underlies the more common form of the disorder.

METHODS

We investigated 50 unrelated patients, with a clinical diagnosis of PPH and no identifiable family history of pulmonary hypertension, by direct sequencing of the entire coding region and intron/exon boundaries of the BMPR2 gene. DNA from available parent pairs (n=5) was used to assess the occurrence of spontaneous (de novo) mutations contributing to sporadic PPH.

RESULTS

We found a total of 11 different heterozygous germline mutations of the BMPR2 gene in 13 of the 50 PPH patients studied, including missense (n=3), nonsense (n=3), and frameshift (n=5) mutations each predicted to alter the cell signalling response to specific ligands. Parental analysis showed three occurrences of paternal transmission and two of de novo mutation of the BMPR2 gene in sporadic PPH.

CONCLUSION

The sporadic form of PPH is associated with germline mutations of the gene encoding the receptor protein BMPR-II in at least 26% of cases. A molecular classification of PPH, based upon the presence or absence of BMPR2 mutations, has important implications for patient management and screening of relatives.

Outcomes of the Kaiser Permanente Tele-Home Health Research Project

CONTEXT

Level of acuity and number of referrals for home health care have been escalating exponentially. As referrals continue to increase, health care organizations are encouraged to find more effective methods for providing high-quality patient care with cost savings.

OBJECTIVE

To evaluate the use of remote video technology in the home health care setting as well as the quality, use, patient satisfaction, and cost savings from this technology.

DESIGN

Quasi-experimental study conducted from May 1996 to October 1997.

SETTING

Home health department in the Sacramento, Calif, facility of a large health maintenance organization.

PARTICIPANTS

Newly referred patients diagnosed as having congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, or need for wound care were eligible for random assignment to intervention (n = 102) or control (n = 110) groups.

INTERVENTION

The control and intervention groups received routine home health care (home visits and telephone contact). The intervention group also had access to a remote video system that allowed nurses and patients to interact in real time. The video system included peripheral equipment for assessing cardiopulmonary status.

MAIN OUTCOME MEASURES

Three quality indicators (medication compliance, knowledge of disease, and ability for self-care); extent of use of services; degree of patient satisfaction as reported on a 3-part scale; and direct and indirect costs of using the remote video technology.

RESULTS

No differences in the quality indicators, patient satisfaction, or use were seen. Although the average direct cost for home health services was $1830 in the intervention group and $1167 in the control group, the total mean costs of care, excluding home health care costs, were $1948 in the intervention group and $2674 in the control group.

CONCLUSIONS

Remote video technology in the home health care setting was shown to be effective, well received by patients, capable of maintaining quality of care, and to have the potential for cost savings. Patients seemed pleased with the equipment and the ability to access a home health care provider 24 hours a day. Remote technology has the potential to effect cost savings when used to substitute some in-person visits and can also improve access to home health care staff for patients and caregivers. This technology can thus be an asset for patients and providers.

Chemotherapy response rates in recurrent/progressive pediatric glioma; results of a systematic review

The optimum treatment strategy for recurrent childhood glioma is unknown. This report presents a systematic analysis of the currently available clinical data on chemotherapeutic management of this disease. A study protocol was prospectively developed outlining the objectives and methods of analysis including literature search strategy, eligibility criteria for published trials to be included, key data elements to be extracted and a plan for statistical analysis. Summary statistics were analyzed for the primary outcome variables. Data on recognized prognostic factors were recorded in order to adjust the outcome measures for these factors. A total of 27 non-randomized clinical trails were included in the analysis. Studies were stratified into 6 chemotherapy classes based on the frequency of drug used across studies. Average median response (complete + partial) across all drug categories was approximately 14% (range 10.4-23.5%). Adding patients with stable disease to complete and partial responders at least doubled average median response rates. Time to tumor progression ranged from 29.4 weeks to 49.7 weeks. The most frequently used drugs were the platinum analogs which demonstrated a mean TTP of 42.0 = /-23.4 weeks. Small sample sizes and the overall poor quality of the available data precluded definitive conclusions regarding the clinical impact of the various drug classes on the natural history of this disease.

A movement-based approach to language development in children who are deaf-blind

A movement-based approach to the development of language in children with deaf-blindness includes utilization of the four coactive movement phases: resonance, coactive movement, nonrepresentation reference, and deferred imitation. Such an approach stresses the use of structure in the environment as well as the use of a hierarchy of media cues. These cues range from concrete to symbolic in their characteristics and assist children in learning more complex concepts. A movement based approach uses the salient features of individuals or objects to develop an understanding of the person or object. Such features initially are used to stimulate use of language concerning objects or individuals in the immediate environment, and later to refer to persons or concepts in a more abstract fashion.

Kaiser Permanente Medical Center's pilot Tele-Home Health Project

This is an interim report of a Kaiser Home Health Department study of the use of telemedicine technology in the home care setting. We present our study design and some early findings from the first six months of the project. Preliminary findings indicate the technology is dependable, and that average telehealth video visits are cost-effective and are about 60% shorter (18 minutes vs. 45 minutes) than on-site visits, with no decrease in patient satisfaction. The study will be completed in September of 1997. This study was initiated in 1996 to explore improving access to health services while maintaining quality of care, and to demonstrate the cost effectiveness of remote consultation technology in the home health setting. The the study, which began in May 1996, employs a randomized design approved by the Institutional Review Board and will be completed in approximately one year. This project was titled Tele-Home Health to acknowledge that a multi-disciplinary team would be composed mainly of nurse case managers, but would also include physical therapists, speech therapists, occupational therapists, home health aides, licensed

Localization of the gene for familial primary pulmonary hypertension to chromosome 2q31-32

Primary pulmonary hypertension (PPH), an often fatal disease, is characterized by elevated pulmonary artery pressures in the absence of a secondary cause. Endovascular occlusion in the smallest pulmonary arteries occurs by proliferation of cells and matrix, with thrombus and vasospasm. Diagnosis is often delayed because the initial symptoms of fatigue and dyspnea on exertion are nonspecific and definitive diagnosis requires invasive procedures. The average life expectancy after diagnosis is two to three years with death usually due to progressive right heart failure. The aetiology of the disease is unknown. Although most cases appear to be sporadic, approximately 6% of cases recorded in the NIH Primary Pulmonary Hypertension Registry are inherited in an autosomal dominant manner with reduced penetrance. Following a genome-wide search using a set of highly polymorphic short tandem repeat (STR) markers and 19 affected individuals from six families, initial evidence for linkage was obtained with two chromosome 2q markers. We subsequently genotyped patients and all available family members for 19 additional markers spanning approximately 40 centiMorgans (cM) on the long arm of chromosome 2. We obtained a maximum two-point lod score of 6.97 at theta = 0 with the marker D2S389; multipoint linkage analysis yielded a maximum lod score of 7.86 with the marker D2S311. Haplotype analysis established a minimum candidate interval of approximately 25 cM.

Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes

OBJECTIVES

To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long-term care in whom urinary retention is a documented problem.

DESIGN

Randomized clinical trial.

SETTING

Three long-term care sites having predominantly male populations.

PARTICIPANTS

Eighty male veterans, residents of three long-term care facilities, ranging in age from 36 to 96 years with a mean age of 72.

INTERVENTIONS

Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident.

MEASUREMENTS

We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed.

RESULTS

No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies.

CONCLUSIONS

Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost-effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique.

Adrenergic and imidazoline receptor-mediated responses to UK-14,304-18 (brimonidine) in rabbits and monkeys. A species difference

Brimonidine is a relatively selective alpha-2 adrenoceptor agonist that is being developed for the treatment of glaucoma. Because brimonidine is chemically related to clonidine and has affinity for the nonadrenergic imidazoline receptor, its ocular effects may be unrelated to alpha-2 receptor activation. The objective of this study was to determine the pharmacology of the intraocular pressure (IOP) response to brimonidine in rabbits and monkeys and the side effects (miosis, cardiovascular depression) in monkeys. Conscious albino rabbits and cynomolgus monkeys were pretreated topically with the following receptor antagonists: rauwolscine (alpha-2), idazoxan (alpha-2, imidazoline), SKF 105854 (vascular postjunctional alpha-2), and prazosin (alpha-1). Intraocular pressure, pupil size, or blood pressure/heart rate was monitored noninvasively for 6 hours following dosing. Binding experiments were performed using [3H]brimonidine in membrane preparations from rabbit iris/ciliary body and from monkey cerebral cortex and brain stem. In rabbits, the ocular hypotensive response to brimonidine was unilateral and was inhibited by rauwolscine > idazoxan >> SKF 105854 = prazosin; this ranked order of potency correlated with displacement of [3H]brimonidine in the rabbit iris/ciliary body. In monkeys, brimonidine decreased IOP bilaterally and suppressed cardiovascular function suggesting a CNS site of action. Intraocular pressure and cardiovascular responses to brimonidine were inhibited by idazoxan >> rauwolscine > SKF 105854 = prazosin; a similar profile was obtained for displacement of [3H]brimonidine in monkey brain tissue. Both rauwolscine and idazoxan inhibited the miotic response to brimonidine in monkeys. Taken together, these results indicate that brimonidine stimulates an ocular alpha-2 adrenoceptor to decrease IOP in the rabbit and a CNS imidazoline receptor to decrease IOP, blood pressure, and heart rate in the cynomolgus monkey. The miotic response in the monkey is mediated by an alpha-2 adrenoceptor. The alpha-1 and vascular postjunctional alpha-2 adrenoceptors do not appear to play a role in mediating these responses.

Participation in transvaginal ovarian cancer screening: compliance, correlation factors, and costs

The objective was to identify factors influencing participation in screening for ovarian cancer using transvaginal sonography in the free experimental program at the University of Kentucky over its 6+ year history. Database records for screenings, performed from 1987 to June 1994, were utilized. Computer sorts, 1990 census information as predictors, and stepwise multiple regression analysis were employed. Participation in the model ovarian screening program took 3-4 years to approach > 300 screens/month, with repeat screenings exceeding new subject participation in this time period. A number of participants traveled > 200 miles for screening on both initial and repeat encounters. Analysis of distance to the screening site, median family income, county physician population, and education levels indicated that distance and then education correlated best with participation. Unit screening cost shrank from $45 to under $25 when maximal participation was achieved. Distance and education correlated with participation. Expenses compare favorably with diagnostic procedures for other diseases.

Teaching strategies for preceptors of beginning intrapartal students

This article describes a variety of ways to help novice students learn the nurse-midwifery skills required when caring for laboring women. The influences of learning style, undergraduate nursing experience, and previous work settings are discussed. The art of nurse-midwifery is emphasized, and ways to encourage and support students are discussed.

Murine model of cutaneous infection with gram-positive cocci

Staphylococcus aureus has remained an important cause of nosocomial wound infections, but standardized or reproducible systems for analyzing cutaneous infections caused by S. aureus do not exist. A variety of foreign materials, variable inocula, and skin traumas have been used to promote infection. To minimize these variables and ensure reproducibility, we chose a model using subcutaneous injections of a fixed quantity of dextran microbeads (Cytodex) as the foreign material added to standardized broth suspensions of S. aureus. Suspensions (0.2 ml) injected into an outbred strain of immunocompetent hairless mice generated reproducible, measurable lesions. With S. aureus Smith Diffuse, fluctuant, erythematous lesions with a peak diameter of 15 mm were observed; these lesions yielded purulent material containing gram-positive cocci and neutrophils and yielded growth of S. aureus on culture. Lesion size was proportional to the bacterial inoculum size. Histologic examination of excised lesions revealed typical abscesses. A second strain of S. aureus (SLC3) produced dermonecrosis instead of abscesses at an inoculum size of 10(7) CFU. Control injections with a sterile Cytodex suspension regularly produced nondraining, nonerythematous nodules with maximum diameters of less than or equal to 5 mm. Streptococcus pyogenes produced late-onset necrotic lesions and abscesses. Using a foreign substance, this model generates easily observed and reproducible cutaneous infection with S. aureus and streptococci that can potentially discriminate between inter- and intrastrain differences. Such a model could be used to test the pathogenicity of isogeneic strains of these bacterial species and to evaluate the efficacy of antimicrobial agents.

Specific associations of T4 bacteriophage proteins with immobilized deoxycytidylate hydroxymethylase

Is the enzymatic machinery for DNA precursor biosynthesis linked to the DNA replication apparatus? To identify intermolecular associations among deoxyribonucleotide biosynthetic enzymes and to ask whether these enzymes are linked to replication proteins, we analyzed radiolabeled T4 bacteriophage proteins that bind specifically to a column of immobilized T4 deoxycytidylate hydroxymethylase. More than a dozen T4 proteins and a few Escherichia coli proteins are adsorbed specifically by this column. Several of the T4 proteins were identified by two-dimensional gel electrophoresis and radioautography. These include five enzymes involved in DNA precursor biosynthesis, dCMP hydroxymethylase, thymidylate synthase, dihydrofolate reductase, dCTPase-dUTPase, and ribonucleotide reductase large and small subunits, plus several proteins of DNA metabolism and replication. Analysis of extracts of cells infected with phage amber mutants defective in specific proteins suggested a specific association involving thymidylate synthase and the gene 32 single-strand DNA-binding protein.

Experience with colposcopy in a family practice center

The experience of a family practice center that performed colposcopy for one year was reviewed to provide insight into the appropriateness of this procedure to a family practice clinic. Almost three thousand Papanicolaou smears were performed, which prompted 97 colposcopy clinic appointments involving 68 patients. Dysplastic Pap smears accounted for 1.82% of the total. Atypical Pap smears occurred in 3.91% of the tests, and 16.1% of a sample of these demonstrated dysplasia. Controversy concerning the atypical Pap smear is discussed. The colposcopy service was convenient for the patients and was at least revenue neutral while providing a new professional opportunity for selected family practitioners. A referral base of at least 1,000 Pap smears might justify a colposcopy program, depending on referral strategies.

Effect of first-grade classroom environment on shy behavior, aggressive behavior, and concentration problems

Investigates the effect of the first-grade classroom environment on the shy behavior, aggressive behavior, and concentration problems of 609 children in 19 East Baltimore public schools. First-grade classroom environment was assessed in terms of dominant pattern of classroom achievement and behavior. Structured teacher ratings assessed child shy behavior, aggressive behavior, and concentration problems at the end of first grade. Children in low-achieving classroom environments had significantly higher teacher ratings of shy behavior and aggressive behavior than children in mixed-achieving or high-achieving environments, even after controlling for potentially confounding child characteristics and classroom behavior environment effects. Analyses controlling for child characteristics and classroom achievement environment effects indicated that children in poor-behaving classroom environments also had significantly higher teacher ratings of shy behavior than children who were not in poor-behaving environments. Subgroup analyses indicated that repeaters in mixed-achieving environments had significantly higher levels of shy behavior compared with nonrepeaters, and repeaters in poor-behaving environments had significantly higher levels of aggressive behavior compared with nonrepeaters. Implications for prevention research are discussed.